Epidemiology of infective endocarditis in Tunisia: a 10-year multicenter retrospective study

Epidemiology, microbiology, and outcomes of infective endocarditis in a tertiary center in Jordan

BACKGROUND

Infective endocarditis (IE) is a relatively rare but serious and life-threatening disease with substantial mortality and morbidity despite progress in diagnostic and treatment techniques. The aim of this study is to investigate the epidemiology, clinical characteristics, microbiological profile, and outcomes of IE patients in a tertiary care facility in Jordan, the Jordan University Hospital (JUH).

METHODS

This is a retrospective case series study which was conducted at JUH. A total of 23 patients with either definite or possible IE according to the Modified Duke Criteria were included in the study. Medical records were reviewed, and relevant information was collected. Descriptive data analysis was performed.

RESULTS

Our study identified a total of 23 patients with infective endocarditis; 65.2% were males, with a mean age of 40.4 years. The majority of patients had an underlying cardiac disease (60.9%), with the most common being congenital heart diseases (17.4%). The most commonly affected valves were the left-side heart valves, with the mitral valve (52.2%) being the most common followed by the aortic valve (34.8%). The most common organism detected in blood culture was Streptococcus viridans (21.7%) followed by methicillin-resistant Staphylococcus aureus. The most common complications among the patients were heart failure and septic shock, and the mortality rate among the patients was 13%.

CONCLUSION

In patients with endocarditis, Streptococcus viridans is the most common culture-positive bacteria at JUH. One third of our patients needed surgical intervention and the mortality rate was 13%.

Application of metagenomic next-generation sequencing in patients with infective endocarditis

Objectives

Metagenomic next-generation sequencing (mNGS) technology is helpful for the early diagnosis of infective endocarditis, especially culture-negative infective endocarditis, which may guide clinical treatment. The purpose of this study was to compare the presence of culture-negative infective endocarditis pathogens versus culture-positive ones, and whether mNGS test results could influence treatment regimens for patients with routine culture-negative infective endocarditis.

Methods

The present study enrolled patients diagnosed with infective endocarditis and tested for mNGS in the First Affiliated Hospital of Zhengzhou University from February 2019 to February 2022 continuously. According to the culture results, patients were divided into culture-negative group (Group CN, n=18) and culture-positive group (Group CP, n=32). The baseline characteristics, clinical data, pathogens, 30 day mortality and treatment regimen of 50 patients with infective endocarditis were recorded and analyzed.

Results

Except for higher levels of PCT in the Group CN [0.33 (0.16-2.74) ng/ml vs. 0.23 (0.12-0.49) ng/ml, P=0.042], there were no significant differences in the basic clinical data and laboratory examinations between the two groups (all P>0.05). The aortic valve and mitral valve were the most involved valves in patients with infective endocarditis (aortic valve involved: Group CN 10, Group CP 16; mitral valve involved: Group CN 8, Group CP 21; P>0.05) while 9 patients had multiple valves involved (Group CN 2, Group CP 7; P>0.05). The detection rate of non-streptococci infections in the Group CN was significantly higher than that in the Group CP (9/18 vs. 3/32, P=0.004). There was no significant difference in patients with heart failure hospitalization and all-cause death at 30 days after discharge (3 in Group CN vs. 4 in Group CP, P>0.05). It is worth noting that 10 patients with culture-negative infective endocarditis had their antibiotic regimen optimized after the blood mNGS.

Conclusions

Culture-negative infective endocarditis should be tested for mNGS for early diagnosis and to guide clinical antibiotic regimen.

Peculiar clinical and diagnostic features of infective endocarditis in Yemen: Comparative analysis with a Western University Hospital

The aim of this study was to describe the pattern, characteristics, and outcomes of infective endocarditis (IE) in Yemen and compare the results with the findings of a Western university hospital. Patients (pts) with a final diagnosis of IE observed in Al-Thawra Sanaa Cardiac Center were prospectively enrolled in 1-year time period. Clinical and diagnostic findings were compared to clinical and diagnostic data of 50 pts with IE observed at Sapienza University Hospital in Rome, Italy. The mean age was 38 ± 6. Predisposing factors for IE were rheumatic heart disease (RHD) in 34 pts (68%), congenital heart disease in 9 pts (18%), prosthetic valve IE in 4 pts (8%), and previous IE in 3 pts (6%). Transthoracic echocardiography (TTE) was done in 50 pts and transesophageal echocardiography (TEE) in 25. Blood cultures were taken in all pts and were positive in 3 pts (6%) and negative in 47 (94%). TTE was positive in 34/50 pts (68%) and TEE in 20/25 (80%). Compared to Sapienza University pts, Al-Thawra Cardiac Center pts had a younger age (p = 0.003), more predisposing RHD (p = 0.0004), less prosthetic heart valves IE (p = 0.002), and more negative blood cultures (p = 0.0001). IE is still a common disease in Yemen among RHD pts and affects the younger age group. It has severe complications which need early diagnosis and proper management. Echocardiography is of prime diagnostic value in the absence of positive blood cultures. An effort should be made to prevent rheumatic fever and RHD.

Infective endocarditis in developing countries: An update

Introduction

Despite advances in diagnostic and treatment, morbidity and mortality due to infective endocarditis (IE) has not decreased. There is a discrepancy in epidemiology of IE between developed and developing countries. Over the last years, increased early detection and consequently prevalence of rheumatic heart disease (RHD) and congenital heart disease (CHD) which are considered predisposing conditions for IE, is noted. Here, we present a review of literature on IE in developing countries.

Methods

We conducted a systematic literature search of IE studies in developing countries through PubMed and Embase. We have divided the studies into two groups: studies published before 2015 (group 1) and studies ≥ 2015 (group 2). The outcome was defined as a difference in epidemiology, microbiology, treatment, and mortality over time. The Scale for Assessment of Narrative Review Articles guidelines was applied.

Findings

In total, 16 studies were included. The total number of IE cases was 1,098 and 1,505 in groups 1 and 2, respectively. We compared 4/7 cohorts from group 1 (n = 789) with 5/9 cohorts from group 2 (n = 636). Six studies were not included in the comparison because they were interacting between the two cohorts. Males predominated in all studies. Rheumatic heart disease was higher in group 1 than in group 2 (42.3% vs. 30.3%, p < 0.001) while for CHD there was no change (17.6% vs. 16.7%, p = 0.672). Streptococci infections was lower in group 1 than group 2 (26.2% vs. 37.7%, p < 0.001). The proportion of Staphylococcus aureus was 15.3% in group 1 and 23.6% in group 2, p < 0.001. Negative blood culture (NBC) was higher in group 1 than in group 2 (42.2% vs. 34.1%, p = 0.002). Patients in group 1 received more surgery than in group 2 (38.8% vs. 28.8%, p < 0.001). Mortality was similar in the two groups (20.9% vs. 22.3%, p = 0.518).

Conclusion

This review shows a scarcity of studies on IE in developing countries. Rheumatic heart disease and congenital heart disease are common predisposing conditions. Other risk factors are prosthetic valves, degenerative valve disease (DVD), intravenous drug use, and human immunodeficiency virus infection. While the proportion of IE cases caused by Streptococcus and Staphylococcus has increased, the number of NBC and patients getting surgery has decreased. Mortality has not changed over time. Timely diagnosis and management of patients with RHD and CHD and comprehensive management of IE are warranted.

Machine Learning-Based Risk Model for Predicting Early Mortality After Surgery for Infective Endocarditis

Background

The early mortality after surgery for infective endocarditis is high. Although risk models help identify patients at high risk, most current scoring systems are inaccurate or inconvenient. The objective of this study was to construct an accurate and easy‐to‐use prediction model to identify patients at high risk of early mortality after surgery for infective endocarditis.

Methods and Results

A total of 476 consecutive patients with infective endocarditis who underwent surgery at 2 centers were included. The development cohort consisted of 276 patients. Eight variables were selected from 89 potential predictors as input of the XGBoost model to train the prediction model, including platelet count, serum albumin, current heart failure, urine occult blood ≥(++), diastolic dysfunction, multiple valve involvement, tricuspid valve involvement, and vegetation >10 mm. The completed prediction model was tested in 2 separate cohorts for internal and external validation. The internal test cohort consisted of 125 patients independent of the development cohort, and the external test cohort consisted of 75 patients from another center. In the internal test cohort, the area under the curve was 0.813 (95% CI, 0.670–0.933) and in the external test cohort the area under the curve was 0.812 (95% CI, 0.606–0.956). The area under the curve was significantly higher than that of other ensemble learning models, logistic regression model, and European System for Cardiac Operative Risk Evaluation II (all, P<0.01). This model was used to develop an online, open‐access calculator (http://42.240.140.58:1808/).

Conclusions

We constructed and validated an accurate and robust machine learning–based risk model to predict early mortality after surgery for infective endocarditis, which may help clinical decision‐making and improve outcomes.

Acute Ischaemic Stroke in Infective Endocarditis: Pathophysiology and Clinical Outcomes in Patients Treated with Reperfusion Therapy

Infective endocarditis in the setting of acute stroke poses a clinical challenge given the high mortality and morbidity associated with the condition. The pathophysiological mechanisms including clinical and imaging biomarkers that can provide insights into clinical trajectories of such patients are of immense interest. The current paper aims to provide a comprehensive overview of acute stroke with infective endocarditis and provide insights into various clinical factors mediating outcomes and therapeutic strategies, specifically in the setting of reperfusion therapy. Prognostic and therapeutic pathways to potentially improve functional outcomes in these patients are also discussed.

A Seventeen-Year Descriptive Study of Infective Endocarditis Features at a Tertiary, Teaching Hospital

Introduction

Infective endocarditis (IE) is a microbial infection affecting the endothelial lining of the heart chambers and valves. Despite advances in diagnostic methods and management, IE still carries high levels of morbidity and mortality. There are no comprehensive data describing incidence, risk factors, and outcomes of IE in Saudi Arabia.

Our study aims to describe the epidemiological and clinical characteristics and outcomes of adult patients with IE treated in a tertiary, Teaching Hospital.

Methods

This is a descriptive, retrospective review of charts (between January 2003 and June 2019) conducted at King Abdulaziz University Hospital. We included all patients 16 years and older with a definitive diagnosis of IE based on Duke Criteria. We collected the following information: demographics, risk factors, comorbidities, microbial type, antibiotic choice, complications, laboratory data, echocardiography data, and mortality.

Results

We found a total of 60 adult patients with definitive diagnoses of IE: 55% of them were males, and the mean age was 48.71 ± 18.3 years. Hypertension was the most common comorbidity, affecting 23 patients (38.3%), followed by end-stage renal disease (ESRD) in 20 patients (33.3%) and diabetes in 17 (28.3%). Staphylococcus aureus was the most common organism (25%), and vancomycin was the most prescribed antibiotic. Fifty-eight patients were treated medically (96.5%). Furthermore, 88% of the patients had vegetations, detected by echocardiography, and the majority had single-valve involvement. Sepsis was the most common complication, and the mortality rate was 36.7%.

Conclusion

There was a small number of definitive IE cases over a 17-years span in our institution. Surprisingly, a higher mortality rate was found among our patients and a lower surgical intervention rate in comparison with the literature. Though we acknowledge the limitations of a retrospective, chart review study, we can speculate that the high mortality rate may be in part related to a higher number of virulent organisms, delayed presentation, and lack of prompt surgical intervention.

Clinical characteristics, microbiology, and outcomes of infective endocarditis in Qatar

Background: Infective endocarditis (IE) is a serious and potentially life-threatening disease. The epidemiology, treatment options, and outcomes have changed considerably over the last two decades. The aim of the study was to describe the epidemiology, clinical characteristics, and outcomes of patients with IE in Qatar.

Methods: Patients were identified from Hamad Medical Corporation hospitals’ electronic records, the national referral center for the State of Qatar. We included those aged ≥ 18 years with Duke Criteria-based diagnosis of IE during the period from January 2015 to September 2017. Demographic and clinical data were retrieved. Descriptive statistics were performed, and logistic regression analysis was used to describe the relationship between patient characteristics and all-cause in-hospital mortality. All potentially relevant variables were included in the univariate analysis, while those with p < 0.1 in the univariate logistic regression model were included in the multivariate analysis. For the final model, we calculated odds ratios (OR) adjusted for each of the variables included, along with their 95% confidence intervals (95% CI). Data were analyzed using STATA software version 15 (StataCorp, College Station, Texas, USA). The study was approved by the Institutional Research Board with a waiver for informed consent.

Results: Fifty-seven cases were included, of which 70% were males. The mean age was 51 years ( ± 16.8 years). Eleven (19%) were associated with prosthetic valves, and 6 (11%) with implantable cardiac devices. Fever (84%), dyspnea (46%), and heart failure (37%) were the most common presentations. Only 58% of patients had known preexisting valvular heart disease or an intracardiac device. Skin infections (10 patients, 18%) were the most prevalent portals of infection, followed by venous catheters, recent valve surgery, and implantable cardiac devices. Staphylococci were implicated in 19 (34%) and Streptococcaceae in 9 (16%) patients, whereas 21 (37%) patients were culture negative. Left-side IE (49 patients, 86%) was predominant. Acute kidney injury (AKI) (17 patients, 30%) and heart failure (11 patients, 19%) were common complications. The majority of patients received targeted antimicrobial therapy with at least two active agents. Only 9 (16%) patients underwent surgical intervention. Fourteen (25%) patients died of any cause before hospital discharge. Logistic regression analysis identified septic shock [OR 57.8, 95% CI 2.6–1360.2; p < 0.01] and AKI OR 33.9, 95% CI 2.9–398.1; p < 0.01) as the only risk factors independently associated with in-hospital mortality.

Conclusion: Staphylococci are the most common microbiological cause of IE in Qatar. Surgical intervention is uncommon, and mortality is relatively high. Our findings suggest that efforts should be directed toward improving IE prevention strategies in high-risk patients, encouraging early microbiological investigations and improving medical and surgical management.

Incidence, Microbiology, and Outcomes in Patients Hospitalized With Infective Endocarditis

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Background:

Despite improvements in management, infective endocarditis remains associated with high mortality and morbidity. We describe temporal changes in the incidence, microbiology, and outcomes of infective endocarditis and the effect of changes in national antibiotic prophylaxis guidelines on incident infective endocarditis.

Methods:

Using a Scotland-wide, individual-level linkage approach, all patients hospitalized with infective endocarditis from 1990 to 2014 were identified and linked to national microbiology, prescribing, and morbidity and mortality datasets. Linked data were used to evaluate trends in the crude and age- and sex-adjusted incidence and outcomes of infective endocarditis hospitalizations. From 2008, microbiology data and associated outcomes adjusted for patient demographics and comorbidity were also analyzed. An interrupted time series analysis was performed to evaluate incidence before and after changes to national antibiotic prophylaxis guidelines.

Results:

There were 7638 hospitalizations (65±17 years, 51% females) with infective endocarditis. The estimated crude hospitalization rate increased from 5.3/100 000 (95% CI, 4.8-5.9) to 8.6/100 000 (95% CI, 8.1–9.1) between 1990 and 1995 but remained stable thereafter. There was no change in crude incidence following the 2008 change in antibiotic prophylaxis guidelines (relative risk of change 1.06 [95% CI, 0.94–1.20]). The incidence rate in patients >80 years of age doubled from 1990 to 2014 (17.7/100 000 [95% CI, 13.4–23.3] to 37.9/100 000 [95% CI, 31.5–45.5]). The predicted 1-year age- and comorbidity-adjusted case fatality rate for a 65-year-old patient decreased in women (27.3% [95% CI, 24.6–30.2] to 23.7% [95% CI, 21.1–26.6]) and men (30.7% [95% CI, 27.7–33.8] to 26.8% [95% CI, 24.0–29.7]) from 1990 to 2014. Blood culture data were available from 2008 (n=2267/7638, 30%), with positive blood cultures recorded in 42% (950/2267). Staphylococcus (403/950, 42.4%) and streptococcus (337/950, 35.5%) species were most common. Staphylococcus aureus and enterococcus had the highest 1-year mortality (adjusted odds ratio 4.34 [95% CI, 3.12–6.05] and 3.41 [95% CI, 2.04–5.70], respectively).

Conclusions:

Despite changes in antibiotic prophylaxis guidelines, the crude incidence of infective endocarditis has remained stable. However, the incidence rate has doubled in the elderly. Positive blood cultures were observed in less than half of patients, with Staphylococcus aureus and enterococcus bacteremia associated with worse outcomes.

Infective endocarditis: innovations in the management of an old disease

The annual incidence of infective endocarditis (IE) is estimated to be between 15 and 80 cases per million persons in population-based studies. The incidence of IE is markedly increased in patients with valve prostheses (>4 per 1,000) or with prior IE (>10 per 1,000). The interaction between platelets, microorganisms and diseased valvular endothelium is the cause of vegetations and valvular or perivalvular tissue destruction. Owing to its complexity, the diagnosis of IE is facilitated by the use of the standardized Duke-Li classification, which combines two major criteria (microbiology and imaging) with five minor criteria. However, the sensitivity of the Duke-Li classification is suboptimal, particularly in prosthetic IE, and can be improved by the use of PET or radiolabelled leukocyte scintigraphy. Prolonged antibiotic therapy is mandatory. Indications for surgery during acute IE depend on the presence of haemodynamic, septic and embolic complications. The most urgent indications for surgery are related to heart failure. In the past decade, the prevention of IE has been reoriented, with indications for antibiotic prophylaxis now limited to patients at high risk of IE undergoing dental procedures. Guidelines now emphasize the importance of nonspecific oral and cutaneous hygiene in individual patients and during health-care procedures.

Characterization, epidemiological profile and risk factors for clinical outcome of infective endocarditis from a tertiary care centre in Turkey

Background: We aimed to investigate the clinical, laboratory, microbiological characteristics of IE in a single tertiary care centre in Turkey and to identify the factors associated with in-hospital mortality. Methods: A total of 155 consecutive adult patients (≥18 years) admitted to our single tertiary care hospital between 2009 and 2019 with definite infective endocarditis were retrospectively included in the study. Results: The mean age of the patients was 58 years. Among 155 endocarditis episodes, 60% involved prosthetic valves, 35.5% had native valve endocarditis (NVE) and 4.5% were device related. Prosthetic valve disease was the most frequent predisposing valve lesion followed by degenerative valvular disease. Vegetations were detected in 103 (66.5%) patients by transthoracic echocardiography and in 145 (93%) patients by transoesophageal echocardiography. The most commonly affected valve was the mitral valve in 84 (54.2%) patients, followed by 67 (43.2%) aortic valve. Staphylococci were the most frequent causative microorganisms isolated in both NVE (31.8%), prosthetic valve endocarditis (38.9%) and device related IE cases. At least one complication was present in 70 patients (45.2%). One hundred and eight patients underwent surgical therapy (69.7%). Age, syncope, heart failure, perforation, septic shock, renal failure, high red cell distribution width, atrial fibrillation, hypocalcaemia, pulmonary hypertension were associated with high mortality. Conclusions: We identified a 10-year presentation of IE in a referral centre in Turkey. Likely other series, we observed more staphylococcus endocarditis with the aging of the population. Surgery was associated with higher in-hospital survival. Age, syncope, perforation, septic shock were independent predictors of mortality.

Epidemiological and clinical profile of infective endocarditis at a Brazilian tertiary care center: an eight-year prospective study

INTRODUCTION

Infective endocarditis (IE) is a systemic infectious disease requiring a multidisciplinary team for treatment. This study presents the epidemiological and clinical data of 73 cases of IE in Rio de Janeiro, Brazil.

METHODS

This observational prospective cohort study of endocarditis patients during an eight-year study period described 73 episodes of IE in 70 patients (three had IE twice). Community-associated (CAIE) and healthcare-acquired infective endocarditis (HAIE) were diagnosed according to the modified Duke criteria. The collected data included demographic, epidemiologic, and clinical characteristics, including results of blood cultures, echocardiographic findings, surgical interventions, and outcome.

RESULTS

Analysis of data from the eight-year study period and 73 cases (70 patients) of IE showed a mean age of 46 years (SD=2.5 years; 1-84 years) and that 65.7% were male patients. The prevalence of CAIE and HAIE was 32.9% and 67.1%, respectively. Staphylococcus aureus (30.1%), Enterococcus spp. (19.1%), and Streptococcus spp. (15.0%) were the prevalent microorganisms. The relevant signals and symptoms were fever (97.2%; mean 38.6 + 0.05°C) and heart murmur (87.6%). Vegetations were observed in the mitral (41.1%) and aortic (27.4%) valves. The mortality rate of the cases was 47.9%.

CONCLUSIONS

In multivariate analysis, chronic renal failure (relative risk [RR]= 1.60; 95% confidence interval [CI] 1.01-2.55), septic shock (RR= 2.19; 95% CI 1.499-3.22), and age over 60 years (RR= 2.28; 95% CI 1.44-3.59) were indirectly associated with in-hospital mortality. The best prognosis was related to the performance of cardiovascular surgery (hazard ratio [HR]= 0.51; 95% CI 0.26-0.99).

[Infectious endocarditis: Experience of a cardiology department at Oran university hospital]

INTRODUCTION

Infectious endocarditis (IE) is a serious disease that has continued to evolve in diagnostic and therapeutic terms.

AIM

To analyze the diagnostic and out come profile.

METHODS

We collected 57 (IE) cases with a definite diagnosis according to the modified Duke criteria. Patients were admitted consecutively to the Cardiology Department of the Oran university hospital from January 2011 to June 2017. Among the variables studied: clinical data, paraclinic data, therapeutic management and hospital outcome.

RESULTS

The mean age was 40.5±15 years (extreme 16-67 years), with a male predominance (sex-ratio=1.5). This was a native valve IE in 70% of cases, on valve prosthesis in 15.5% of patients, on congenital heart disease in 2% and on pacemaker probe in 4% of cases. The entrance door was dominated by oral origin. Blood cultures were positive only in 51% of cases. The most commonly implicated organism in staphylococci in 22.6%, streptococcus in 18.9% and brucellosis in 3.8%. Ultrasound data revealed vegetation (83%), cardiac abscess (19%), valvular perforation (15.1%) and prosthesis disintegration (7.5%). Complications were mainly neurological complications (27%) and hemodynamics (26%). Cardiac surgery occurred in 29% of patients. Hospital mortality was 26%, predictive factors were staphylococcal AI (P<0.001), cardiac insufficiency (P<0.001) and neurological complications (P=0.04).

CONCLUSION

Infectious endocarditis is a serious disease in the absence of surgery. The diagnosis is based on echocardiography in the first place and blood cultures. The population is often young revealing the EI by complications; its prevention is the best way to improve its prognosis.

Early results for active infective endocarditis

Introduction

Cardiac surgery is frequently needed during active phase of infective endocarditis (IE). The purpose of this study was to analyze the immediate and late results and determine the risk factors for death.

Methods

We retrospectively reviewed 101 patients with IE operated in the active phase. The mean age was 40.5 ± 12.5 years. 16 patients (15.8%) were diagnosed with prosthetic valve endocarditis (PVE). 81 (80.9%) were in NYHA functional class III-IV. Blood cultures were positive in only 24 cases (23.9%).

Results

in-hospital mortality rate was 17.9% (18 cases). Multivariate analysis indentified five determinant predictor factors: congestive heart failure (CHF), renal insufficiency, high Euroscore, prolonged cardiopulmonary bypass time (> 120 min) and long ICU stay. The median follow-up period was 4.2 (2-6.5) years. Overall survival rate for all patients who survived surgery was 97% at 5 years and 91% at 10 years.

Conclusion

Despite high in-hospital mortality rate, when patients receive operation early in the active phase of their illness, late outcome may be good.

Endocarditis in the Mediterranean Basin

Infective endocarditis is a severe disease with high mortality. Despite a global trend towards an increase in staphylococcal aetiologies, in older patients and a decrease in viridans streptococci, we have observed in recent studies great epidemiologic disparities between countries. In order to evaluate these differences among Mediterranean countries, we performed a PubMed search of infective endocarditis case series for each country. Data were available for 13 of the 18 Mediterranean countries. Despite great differences in diagnostic strategies, we could classify countries into three groups. In northern countries, patients are older (>50 years old), have a high rate of prosthetic valves or cardiac electronic implantable devices and the main causative agent is Staphylococcus aureus. In southern countries, patients are younger (<40 years old), rheumatic heart disease remains a major risk factor (45–93%), viridans streptococci are the main pathogens, zoonotic and arthropod-borne agents are frequent and blood culture–negative endocarditis remains highly prevalent. Eastern Mediterranean countries exhibit an intermediate situation: patients are 45 to 60 years old, the incidence of rheumatic heart disease ranges from 8% to 66%, viridans streptococci play a predominant role and zoonotic and arthropod-borne diseases, in particular brucellosis, are identified in up to 12% of cases.

Microbiological profile and risk factors for in-hospital mortality of infective endocarditis in tertiary care hospitals of south Vietnam

Objectives

We aimed to evaluate the microbiological characteristics and risk factors for mortality of infective endocarditis in two tertiary hospitals in Ho Chi Minh City, south Vietnam.

Materials and methods

A retrospective study of 189 patients (120 men, 69 women; mean age 38 ± 18 years) with the diagnosis of probable or definite infective endocarditis (IE) according to the modified Duke Criteria admitted to The Heart Institute or Tam Duc Hospital between January 2005 and December 2014.

Results

IE was related to a native valve in 165 patients (87.3%), and prosthetic valve in 24 (12.7%). Of the 189 patients in our series, the culture positive rate was 70.4%. The most common isolated pathogens were Streptococci (75.2%), Staphylococci (9.8%) followed by gram negative organism (4.5%). The sensitivity rate of Streptococci to ampicillin, ceftriaxone or vancomycin was 100%. The rate of methicillin resistant Staphylococcus aureus was 40%. There was a decrease in penicillin sensitivity for Streptococci over three eras: 2005–2007 (100%), 2008–2010 (94%) and 2010–2014 (84%). The in-hospital mortality rate was 6.9%. Logistic regression analysis found prosthetic valve and NYHA grade 3 or 4 heart failure and vegetation size of more than 15 mm as strong predictors of in-hospital mortality.

Conclusion

Streptococcal species were the major pathogen of IE in the recent years with low rates of antimicrobial resistance. Prosthetic valve involvement, moderate or severe heart failure and vegetation size of more than 15 mm were independent predictors for in-hospital mortality in IE.

Short- and long-term outcomes in infective endocarditis patients: a systematic review and meta-analysis

Background

Despite advances in medical knowledge, technology and antimicrobial therapy, infective endocarditis (IE) is still associated with devastating outcomes. No reviews have yet assessed the outcomes of IE patients undergoing short- and long-term outcome evaluation, such as all-cause mortality and IE-related complications. We conducted a systematic review and meta-analysis to examine the short- and long-term mortality, as well as IE-related complications in patients with definite IE.

Methods

A computerized systematic literature search was carried out in PubMed, Scopus and Google Scholar from 2000 to August, 2016. Included studies were published studies in English that assessed short-and long-term mortality for adult IE patients. Pooled estimations with 95% confidence interval (CI) were calculated with DerSimonian-Laird (DL) random-effects model. Sensitivity and subgroup analyses were also performed. Publication bias was evaluated using inspection of funnel plots and statistical tests.

Results

Twenty five observational studies (retrospective, 14; prospective, 11) including 22,382 patients were identified. The overall pooled mortality estimates for IE patients who underwent short- and long-term follow-up were 20% (95% CI: 18.0–23.0, P < 0.01) and 37% (95% CI: 27.0–48.0, P < 0.01), respectively. The pooled prevalence of cardiac complications in patients with IE was found to be 39% (95%CI: 32.0–46.0) while septic embolism and renal complications accounted for 25% (95% CI: 20.0–31) and 19% (95% CI: 14.0–25.0) (all P < 0.01), respectively.

Conclusion

Irrespective of the follow-up period, a significantly higher mortality rate was reported in IE patients, and the burden of IE-related complications were immense. Further research is needed to assess the determinants of overall mortality in IE patients, as well as well-designed observational studies to conform our results.

Electronic supplementary material

The online version of this article (10.1186/s12872-017-0729-5) contains supplementary material, which is available to authorized users.

Infective Endocarditis in French West Indies: A 13-Year Observational Study

We conducted an observational study to describe the characteristics of infective endocarditis (IE) in French West Indies (FWI) and to identify variables associated with in-hospital case fatality. The records of the patients admitted for IE to the University Hospital of Martinique between 2000 and 2012 were collected using an electronic case report form. Only Duke-Li definite cases were considered for this analysis. Variables associated with in-hospital mortality were tested using univariate logistic regression analysis. The analysis included 201 patients (median age 58 years, sex ratio: two males to one female). There was no previously known heart disease in 45.8%, a prosthetic valve in 21.4%, and previously known native valve disease in 32.8% of the cases. Community-acquired IE represented 59.7% of all cases, health-care-associated IE represented 38.3% and injection-drug-use-acquired IE represented 1.5%. Locations of IE were distributed as follows: 42.3% were mitral valve IE, 34.8% were aortic valve IE, and 7% were right-sided IE. Microorganisms recovered from blood cultures included 30.4% streptococci, 28.9% staphylococci, and 5% enterococci. Blood cultures were negative in 20.9% of the cases. Surgical treatment was performed in 53% of the patients. In-hospital case fatality rate was 19%. Advanced age, Staphylococcus aureus IE, and health-care-associated IE were associated with in-hospital case fatality. The epidemiological and microbiological profile of IE in FWI is in between those observed in developed countries and developing countries: patients were younger, blood cultures were more frequently negative, and IE due to group D streptococci and enterococci were less common than in industrialized countries.

Clinical features and prognosis of infective endocarditis in children: Insights from a Tunisian multicentre registry

BACKGROUND

Infective endocarditis (IE) is a rare condition in the paediatric setting. No data on the epidemiology and prognosis of IE in children are available from North African countries.

AIM

To investigate the epidemiological profile and prognosis of IE in children in Tunisia.

METHODS

All patients aged≤18 years presenting with IE in three Tunisian tertiary care centres between January 1997 and September 2013 were included. Clinical features and 30-day and 6-month mortality rates were studied. Factors predictive of death at 6-month follow-up were determined.

RESULTS

A total of 73 patients were included in the present study. The mean age was 12±4.8 years; 35 (50.7%) patients were male. Rheumatic heart disease (RHD) was the underlying heart disease in 17 (23.3%) cases and IE occurred in a structurally normal heart in 36 (49.3%) cases. Staphylococcus species were isolated in 17 (23.3%) cases. Regarding IE localization, the mitral valve was involved in 28 (38.4%) cases and the aortic valve in 14 (19.2%) cases. Recourse to surgery was reported in 37 (50.7%) cases. Thirty-day and 6-month mortality rates were 13.6% and 19.2%, respectively. Heart failure on admission or during the hospital course, acute renal failure and neurological complications were significantly associated with death at 6-month follow-up in the univariate analysis and after adjustment for age and sex.

CONCLUSIONS

In the Tunisian context, IE in children is still characterized by the high prevalence of RHD as an underlying heart disease. Short- and long-term mortality rates remain high. Heart failure, acute renal failure and neurological complications are significantly associated with death at 6-month follow-up.

The Changing Epidemiology of Infective Endocarditis in the Twenty-First Century

PURPOSE OF THE REVIEW

Infective endocarditis (IE) is a relatively infrequent infectious disease. It does, however, causes serious morbidity, and its mortality rate has remained unchanged at approximately 25%. Changes in IE risk factors have deeply impacted its epidemiology during recent decades but literature from low-income countries is very scarce. Moreover, prophylaxis guidelines have recently changed and the impact on IE incidence is still unknown.

RECENT FINDINGS

In high-income countries, the proportion of IE related to prior rheumatic disease has decreased significantly and has been replaced proportionally by cases related to degenerative valvulopathies, prosthetic valves, and cardiovascular implantable electronic devices. Nosocomial and non-nosocomial-acquired cases have risen, as has the proportion caused by staphylococci, and the median age of patients. In low-income countries, in contrast, rheumatic disease remains the main risk factor, and streptococci the most frequent causative agents. Studies performed to evaluate impact of guidelines changes' have shown contradictory results. The increased complexity of cases in high-income countries has led to the creation of IE teams, involving several specialties. New imaging and microbiological techniques may increase sensitivity for diagnosis and detection of IE cases. In low-income countries, IE remained related to classic risk factors. The consequences of prophylaxis guidelines changes are still undetermined.

Infective Endocarditis in Low- and Middle-Income Countries

Infective endocarditis (IE) is a rare, life-threatening disease with a mortality rate of 25% and significant debilitating morbidities. Although much has been reported on contemporary IE in high-income countries, conclusions on the state of IE in low- and middle-income countries (LMICs) are based on studies conducted before the year 2000. Furthermore, unique challenges in the diagnosis and management of IE persist in LMICs. This article reviews IE studies conducted in LMICs documenting clinical experiences from the year 2000 to 2016. Presented are the causes of IE, management of patients with IE, and prevailing challenges in diagnosis and treatment of IE in LMICs.

Asymptomatic and symptomatic embolic events in infective endocarditis: associated factors and clinical impact

Background

Embolic complications of infective endocarditis are common. The impact of asymptomatic embolism is uncertain.

Objectives

To determine the frequency of emboli due to IE and to identify events associated with embolism.

Methods

Retrospective analysis of an endocarditis database, prospectively implemented, with a post hoc study driven by analysis of data on embolic events. Data was obtained from the International Collaboration Endocarditis case report forms and additional information on embolic events and imaging reports were obtained from the medical records. Variables associated with embolism were analyzed by the statistical software R version 3.1.0.

Results

In the study period, 2006–2011, 136 episodes of definite infective endocarditis were included. The most common complication was heart failure (55.1%), followed by embolism (50%). Among the 100 medical records analyzed for emboli in left-sided infective endocarditis, 36 (36%) were found to have had asymptomatic events, 11 (11%) to the central nervous system and 28 (28%) to the spleen. Cardiac surgery was performed in 98/136 (72%). In the multivariate analysis, splenomegaly was the only associated factor for embolism to any site (p < 0.01, OR 4.7, 95% CI 2.04–11). Factors associated with embolism to the spleen were positive blood cultures (p = 0.05, OR 8.9, 95% CI 1.45–177) and splenomegaly (p < 0.01, OR 9.28, 95% CI 3.32–29); those associated to the central nervous system were infective endocarditis of the mitral valve (p < 0.05, OR 3.5, 95% CI 1.23–10) and male gender (p < 0.05, OR 3.2, 95% CI 1.04–10). Splenectomy and cardiac surgery did not impact on in-hospital mortality.

Conclusions

Asymptomatic embolism to the central nervous system and to the spleen were frequent. Splenomegaly was consistently associated with embolic events.

Infective endocarditis in Principal Hospital of Dakar: a retrospective study of 42 cases over 10 years

Infective Endocarditis (IE) is an endocardial infection usually caused by bacteria that affects not only the native heart valves but also, with increasing frequency intravascular implanted devices and congenital heart diseases. Despite medical advances, IE remains a life-threatening disease with substantial morbidity and mortality. In Africa, its diagnosis and treatment are still a major challenge in clinical practice. The objective of this work was to study the epidemiological, clinical features, diagnostic techniques currently used in medical practice and the range of micro-organisms that are responsible. This was a retrospective study done at Principal Hospital of Dakar. We include all patients who were admitted with clinical manifestations of definite or possible IE according to the extended DUKE criteria between January 1^st, 2005 and December 31^st, 2014. We collected and analyzed epidemiological, clinical, paraclinical and outcomes data of 42 patients. Hospital prevalence of IE was 0.078% (42/53711). The mean age was 27.5+/- 18 years with a sex ratio (M/F) of 0.55. IE were more common in patients with damaged or abnormal heart valves (78.6%) and in thoses with underlying structural defects (14.3%). The most common presenting symptoms were fever (90%) and cardiac murmurs (81%). Extracardiac clinical manifestations were very rare. The usual laboratory parameters of inflammation were elevated in 90% of patients. Blood cultures were negative in 50% of cases and positive in 21.4%. The main organism found was Staphylococcus aureus. Echocardiography found vegetations in 95.2% of cases, chamber enlargement in 73.8% and mitral regurgiation in 83.3%. Broad-spectrum penicillins including ampicillin and gentamycine were used for all patients. Major complications were heart failure (47.6%). Strokes and cerebral abcess (23.8%) and Vascular emboli 14.3%. Hospital mortality was 31%. IE remains a life-threatening disease with hight mortality despites improved techniques of diagnosis and modern antibiotics.

Evaluation of epidemiological, clinical, and microbiological features of definite infective endocarditis

Background: Infective endocarditis (IE) is a microbial infection of heart valves and its endothelial lining which is considered as a life-threatening disorder. This study evaluated the epidemiological, clinical, and microbiological features of IE at the Cardiovascular Research Center in Yazd, Iran.

Methods: The cross-sectional study was conducted on 20 patients diagnosed with definite IE on the basis of Duke’s criteria hospitalized for one year in the Cardiovascular Research Center in Yazd, Iran, from January 2015 to December 2015. Demographic information, clinical, laboratory, and microbiological findings, and also trans-esophageal echocardiography (TEE) of each patient were recorded and assessed. The collected data were analyzed using SPSS 16.

Results: The mean age of the patients under study was 45±16 years with most of the afflicted patients (60%) being male. Most cases (70%) of IE were observed in the warm seasons (spring and summer). The most common clinical sign (80%) was fever. TEE was positive for all (100%) patients, and vegetation was seen in all patients. The nosocomial mortality rate was zero. However, 14 (70%) patients underwent surgical treatment. The valves afflicted with IE were: the mitral valve (40%), the aortic valve (35%), and the tricuspid valve (25%), respectively. 4 patients (20%) had a positive history of IE. Blood culture test was positive only in 1 case and the isolated microorganism belonged to the viridans group streptococci.

Conclusion: Despite the one-year high prevalence of IE in this study, the nosocomial mortality rate was not high and was reported to be nil under surgical and antimicrobial therapy.

Characteristics of Infective Endocarditis in a Tertiary Hospital in East China

The epidemiology, clinical presentation, and treatment of infective endocarditis (IE) has significantly changed over the past few years in developed countries. However, relevant data from developing countries are different and remain scarce. The objective of this study was to evaluate the clinical presentations, treatment and outcomes of IE patients in a tertiary hospital in East China over an 8-year period. This was a retrospective observational study of consecutive cases of definite or possible IE as per the modified Duke criteria between January 2008 and December 2015. A total of 135 definite and 39 probable IE cases were identified. The mean age was 47.8 ± 15.7 years, with a male preponderance (1.9: 1). Degenerative valve disease accounted for 30.5% cases of IE, followed by congenital heart disease (29.9%) and rheumatic heart disease (14.9%). Native cardiac valves were present in 93.7% of the IE patients. Echocardiography and blood culture were performed in all patients, of whom 55.2% were found to have large vegetations (≥10 mm) and the positive rate of blood culture was 60.3%. Streptococcus remained the chief causative agent that was identified in 61.9% of culture-positive patients. Glycopeptide antibacterials and cephalosporins were the most frequently used antimicrobial drugs for IE therapy. Seventy-six (43.7%) of the IE patients were surgically treated. The mortality rate during hospital stay was 10.9%. Our data reflected clinical and microbiological profile, and treatment of IE in a tertiary hospital located in the East China.

The causative agents in infective endocarditis: a systematic review comprising 33,214 cases

Infective endocarditis (IE) incidence remains high with considerable fatality rates; guidelines for prophylaxis against IE are currently under review in some settings which highlights the importance of maintaining up-to-date epidemiological estimates about the most common microbial causes. The objective of this systematic review, following PRISMA guidelines, was to identify the most common microbial causes of IE in recent years. Medline was searched from January 1, 2003 to March 31, 2013 for all articles containing the term "infective endocarditis". All relevant studies reporting diagnostic results were included. Special patient subpopulations were assessed separately. A total of 105 studies were included, from 36 countries, with available data on a total of 33,214 cases. Staphylococcus aureus was found to be the most common microorganism, being the most frequent in 54.3 % of studies (N = 57) (and in 55.4 % of studies using Duke's criteria for diagnosis [N = 51]). Viridans group streptococci (VGS), coagulase-negative staphylococci (CoNS), Enterococcus spp and Streptococcus bovis were among the most common causes. S. aureus was the most common pathogen in almost all population subgroups; however, this was not the case in patients with implantable devices, prosthetic valves, or immunocompromised non-HIV, as well as in the sub-group from Asia, emphasizing that a global one-size-fits-all approach to the management of suspected IE is not appropriate. This review provides an evidence-based map of the most common causative agents of IE, highlighting S. aureus as the leading cause in the 21st century. The changing epidemiology of IE in some patient sub-groups in the last decade and the very high number of microbiologically undiagnosed cases (26.6 %) suggest the need to revisit IE prophylaxis and diagnostic strategies.

Diagnosis of blood culture-negative endocarditis and clinical comparison between blood culture-negative and blood culture-positive cases

PURPOSE

To analyze the clinical characteristics of blood culture-negative endocarditis (BCNE) and how it compares to those of blood culture-positive endocarditis (BCPE) cases and show how molecular tools helped establish the etiology in BCNE.

METHODS

Adult patients with definite infective endocarditis (IE) and having valve surgery were included. Valves were studied by polymerase chain reaction (PCR). Statistical analysis compared BCNE and BCPE.

RESULTS

One hundred and thirty-one patients were included; 53 (40 %) had BCNE. The mean age was 45 ± 16 years; 33 (62 %) were male. BCNE was community-acquired in 41 (79 %). Most patients were referred from other hospitals (38, 73 %). Presentation was subacute in 34 (65 %), with fever in 47/53 (90 %) and a new regurgitant murmur in 34/42 (81 %). Native valves were affected in 74 %, mostly left-sided. All echocardiograms showed major criteria for IE. Antibiotics were used prior to BC collection in 31/42 (74 %). Definite histological diagnosis was established for 35/50 (70 %) valves. PCR showed oralis group streptococci in 21 (54 %), S. aureus in 3 (7.7 %), gallolyticus group streptococci in 2 (5.1 %), Coxiella burnetii in 1 (2.5 %) and Rhizobium sp. in 1 (2.5 %). In-hospital mortality was 9/53 (17 %). Fever (p = 0.06, OR 4.7, CI 0.91-24.38) and embolic complications (p = 0.003, OR 3.3, CI 1.55-6.82) were more frequent in BCPE cases, while new acute regurgitation (p = 0.05, OR 0.3, CI 0.098-0.996) and heart failure (p = 0.02, OR 0.3, CI 0.13-0.79) were less so.

CONCLUSIONS

BCNE resulted mostly from prior antibiotics and was associated with severe hemodynamic compromise. Valve histopathology and PCR were useful in confirming the diagnosis and pointing to the etiology of BCNE.

Global and regional burden of infective endocarditis, 1990-2010: a systematic review of the literature

Infective endocarditis (IE) is a life-threatening disease associated with serious complications. The GBD 2010 (Global Burden of Disease, Injuries, and Risk Factors) study IE expert group conducted a systematic review of IE epidemiology literature to inform estimates of the burden on IE in 21 world regions in 1990 and 2010. The disease model of IE for the GBD 2010 study included IE death and 2 sequelae: stroke and valve surgery. Several medical and science databases were searched for IE epidemiology studies in GBD high-, low-, and middle-income regions published between 1980 and 2008. The epidemiologic parameters of interest were IE incidence, proportions of IE patients who developed stroke or underwent valve surgery, and case fatality. Literature searches yielded 1,975 unique papers, of which 115 published in 10 languages were included in the systematic review. Eligible studies were population-based (17%), multicenter hospital-based (11%), and single-center hospital-based studies (71%). Population-based studies were reported from only 6 world regions. Data were missing or sparse in many low- and middle-income regions. The crude incidence of IE ranged between 1.5 and 11.6 cases per 100,000 people and was reported from 10 countries. The overall mean proportion of IE patients that developed stroke was 0.158 ± 0.091, and the mean proportion of patients that underwent valve surgery was 0.324 ± 0.188. The mean case fatality risk was 0.211 ± 0.104. A systematic review for the GBD 2010 study provided IE epidemiology estimates for many world regions, but highlighted the lack of information about IE in low- and middle-income regions. More complete knowledge of the global burden of IE will require improved IE surveillance in all world regions.

Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management

Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.

Prospective comparison of infective endocarditis in Khon Kaen, Thailand and Rennes, France

Prospectively collected, contemporary data are lacking on how the features of infective endocarditis (IE) vary according to region. We, therefore, compared IE in Rennes, France and Khon Kaen, Thailand. Fifty-eight patients with confirmed IE were enrolled at each site during 2011 and 2012 using a common protocol. Compared with French patients, Thais had a lower median age (47 versus 70 years old; P < 0.001) and reported more animal contact (86% versus 21%; P < 0.001). There were more zoonotic infections among Thai than France patients (6 and 1 cases; P = 0.017) and fewer staphylococcal infections (4 versus 15 cases; P = 0.011). Underlying rheumatic heart disease was more prevalent in Thai than in French patients (31% and 4%; P = 0.001), whereas prosthetic heart valves were less prevalent (9% and 35%; P = 0.001). Our data strengthen previous observations that IE in the tropics has distinctive demographic characteristics, risk factors, and etiologies and underscore the need for improved prevention and control strategies.

Infective endocarditis in Ethiopian children: a hospital based review of cases in Addis Ababa

Introduction

Infective endocarditis is an infection of the endocardial lining of the heart mainly associated with congenital and rheumatic heart disease. Although it is a rare disease in children, it is associated with high morbidity and mortality; death due to infective endocarditis has been reported to be as high as 26% in sub-Saharan Africa.

Methods

This was a retrospective review of routinely collected data from patient records.

Results

A total of 40 children (71% female) with 41 episodes of infective endocarditis admitted to a general paediatric ward in Addis Ababa, Ethiopia between 2008 and 2013. Age ranged from 7 months to 14 years, with a median of 9 years (Inter quartile Range: 7-12 years). Rheumatic and congenital heart diseases were underlying risk factors in 49% and 51% of cases respectively. Congestive heart failure, systemic embolization and death occurred in 66%, 12% and 7.3% respectively. Death was associated with the occurrence of systemic embolization (P-value = 0.03).

Conclusion

Rheumatic heart disease was an important predisposing factor for infective endocarditis in Ethiopian children. Late presentations of cases were evidenced by high proportion of complications such as congestive heart failure. A low rate of clinically evident systemic embolization in this study may be a reflection of the diagnostic challenges. High proportion of prior antibiotic intake might explain the cause of significant BCNE. Preventive measures like primary and secondary prophylaxis of rheumatic fever may decrease the associated morbidity and mortality. Early detection and referral of cases, awareness creation about indiscriminate use of antimicrobials, and proper history taking and documentation of information recommended.

Infective endocarditis in the Lao PDR: clinical characteristics and outcomes in a developing country

INTRODUCTION

Data on infective endocarditis (IE) in Southeast Asia are scarce.

OBJECTIVES

To describe the clinical epidemiology of IE in Lao PDR, a lower middle-income country.

METHODS

A single centre retrospective study at Mahosot Hospital, Vientiane. Patients aged over 1year of age admitted 2006-2012 to Mahosot Hospital with definite or possible IE by modified Duke criteria were included.

RESULTS

Thirty-six patients fulfilled the inclusion criteria; 33 (91.7%) had left-sided IE. Eleven (30.6%) had definite IE and 25 (69.4%) possible left-sided IE. Median age was 25years old [IQR 18-42]. Fifteen patients (41.7%) were males. Underlying heart diseases included: rheumatic valve disease in 12 (33.3%), congenital heart disease in 7 (19.4%), degenerative valve disease in 3 (8.3%), and of unknown origin in 14 (38.9%) patients. Native valve IE was present in 30 patients (83.3%), and prosthetic valve IE in 6 patients (16.7%). The most frequent pathogens were Streptococcus spp. in 7 (19.4%). Blood cultures were negative in 22 patients (61.1%). Complications included: heart failure in 11 (30.6%), severe valve regurgitation in 7 (19.4%); neurological event in 7 (19.4%); septic shock or severe sepsis in 5 (13.9%); and cardiogenic shock in 3 patients (8.3%). No patient underwent heart surgery. Fourteen (38.9%) had died by follow-up after a median of 2.1years [IQR 1-3.2]; and 3 (8.3%) were lost to follow-up.

CONCLUSIONS

Infective endocarditis, a disease especially of young adults and mainly caused by Streptococcus spp., was associated with rheumatic heart disease and had high mortality in Laos.

Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases

OBJECTIVE

In order to define the current characteristics of infective endocarditis (IE) in Turkey, we evaluated IE cases over a 14-year period in a tertiary referral hospital.

METHODS

All adult patients who were hospitalized in our hospital with a diagnosis of IE between 2000 and 2013 were included in the study. Modified Duke criteria were used for diagnosis. The Chi-square test, Student's t-test, Mann-Whitney U-test, Cox and logistic regression analysis were used for the statistical analysis.

RESULTS

There were 325 IE cases during the study period. The mean age of the patients was 47 years. Causative microorganisms were identified in 253 patients (77.8%) and included staphylococci (36%), streptococci (19%), enterococci (7%), and Brucella spp (5%). A streptococcal aetiology was associated with younger age (<40 years) (p=0.001), underlying chronic rheumatic heart disease (CRHD) (odds ratio (OR) 3.89) or a congenital heart defect (OR 4.04), community acquisition (OR 17.93), and native valve (OR 3.68). A staphylococcal aetiology was associated with healthcare acquisition (OR 2.26) or pacemaker lead-associated endocarditis (OR 6.63) and an admission creatinine level of >1.2mg/dl (OR 2.15). Older age (>50 year) (OR 3.93), patients with perivalvular abscess (OR 9.18), being on dialysis (OR 6.22), and late prosthetic valve endocarditis (OR 3.15) were independent risk factors for enterococcal IE. Independent risk factors for mortality in IE cases were the following: being on dialysis (hazard ratio (HR) 4.13), presence of coronary artery heart disease (HR 2.09), central nervous system emboli (HR 2.33), and congestive heart failure (HR 2.15). Higher haemoglobin (HR 0.87) and platelet (HR 0.996) levels and surgical interventions for IE (HR 0. 33) were found to be protective factors against mortality.

CONCLUSIONS

In Turkey, IE occurs in relatively young patients and Brucella spp should always be taken into consideration as a cause of this infection. We should first consider streptococci as the causative agents of IE in young patients, those with CRHD or congenital heart valve disease, and cases of community-acquired IE. Staphylococci should be considered first in the case of pacemaker lead IE, when there are high levels of creatinine, and in cases of healthcare-associated IE. Enterococci could be the most probable causative agent of IE particularly in patients aged >50 years, those on dialysis, those with late prosthetic valve IE, and those with a perivalvular abscess. The early diagnosis and treatment of IE before complications develop is crucial because the mortality rate is high among cases with serious complications. The prevention of bacteraemia with the measures available among chronic haemodialysis patients should be a priority because of the higher mortality rate of subsequent IE among this group of patients.

Changing profile of infective endocarditis: a clinicopathologic study of 220 patients in a single medical center from 1998 through 2009

The epidemiologic profile of infective endocarditis has changed substantially over the past few years, especially in industrialized countries. Our study evaluates the clinical and pathologic characteristics of infective endocarditis patients treated by cardiac surgery in China during a 12-year period. We retrospectively evaluated 220 surgically treated infective endocarditis patients and analyzed their changes from the beginning of 1998 through 2009. The mean age of the patients increased from 36.9 to 42.7 years during those 12 years (P=0.036). The chief predisposing disease was congenital heart disease (32.8%), rather than rheumatic heart disease (13.2%); this rate did not change significantly during the 12 years. The prevalent congenital lesion was bicuspid aortic valve, the rate of which (55.6%) increased significantly over the 3 time intervals studied (P=0.016). The frequency of infective endocarditis after non-dental surgical and nonsurgical intervention was significantly greater (23.3%) during 1998 through 2001, compared with the 2 intervals that followed (9%; P=0.019). Streptococcus viridans was the most frequent causative agent overall (25.6%). Forty-seven of the 220 patients (21.4%) carried the clinical diagnosis of some other form of heart disease before surgery, but at surgery they were found to have infective endocarditis as the fundamental disease process. Of 47 patients, 33 (70.2%) had either very small or no vegetations but had focal necrosis and inflammation of valve tissue that supported the diagnosis of infective endocarditis.

Epidemiology of infective endocarditis in a tertiary-center in Jerusalem: a 3-year prospective survey

BACKGROUND

Epidemiological features of infective endocarditis have changed during the last decades because of increases in the prevalence of health care exposure and of Staphylococcus aureus bloodstream infection. Consequently, the role of surgery is evolving. We aim to provide a contemporary profile of epidemiological, microbiological, and clinical features of infective endocarditis in a tertiary medical center, and identify predictors of mortality.

METHODS

A prospective observational cohort study of consecutive adult patients with definite endocarditis according to the modified Duke criteria. Data were collected from January 1, 2009 through October 31, 2011 following a predefined case report form designed by the ICE-PCS.

RESULTS

Among 70 endocarditis episodes, 25.7% involved prosthetic valves and 11.5% were device related. Forty-four percent of episodes were health-care associated. The predominant causative microorganism on native valve, prosthetic valve and device related endocarditis was Staphylococcus aureus (33.3%). Viridans group streptococci accounted for the majority of community-acquired endocarditis (36.1%). At least one complication occurred in 50% of the episodes. One third of the patients who had an indication for surgery were operated upon. Six month case fatality ratio was 40%. Sixty-five percent of patients with a contraindication to surgery died, compared with 9% and 28.5% who were treated surgically and medically, respectively. In multivariable analysis, age was a predictor of mortality.

CONCLUSION

Compared with other series, we observed more health-care associated endocarditis, and a higher mortality. Nearly half of all deaths were in patients who had a contraindication to surgery. Careful evaluation of contraindications to surgery is warranted.

The epidemiology and outcomes of infective endocarditis in a tertiary care hospital in Oman

OBJECTIVES

We undertook this study to describe the epidemiological and clinical features of infective endocarditis (IE) and to study the complications and management of IE in a tertiary care hospital in Oman.

METHODS

This is a retrospective study of 58 adult patients (>13 years of age) admitted to the Royal Hospital with IE from June 2006 to June 2011.

RESULTS

Of the 58 patients, 40 (69%) were males, and 18 (31%) were females (ratio 2.2). The median age was 43.6 years (range: 14-85). Forty-eight cases (82.7%) had native valves, nine patients (15.6%) had prosthetic valves, and one case (1.7%) had a pacemaker. The most commonly involved valves were mitral (33, 56.9%) and aortic (23, 39.7%). The blood cultures were positive in 47 (81%) patients, and the most commonly isolated organisms were Streptococci spp., which were found in 20 (34.5%) patients, and Staphylococci spp., which were found in 19 (32.8%) patients. The complication rate was 21%. A total of 15 (25.9%) patients underwent surgical intervention, and the in-hospital mortality rate was 27.6%.

CONCLUSIONS

Native-valve IE is the predominant type of endocarditis and is more of an acute disease. The prevalence of Staphylococci spp. IE is similar to that of Streptococci spp. IE, and its associated mortality remains high.

Infective endocarditis epidemiology over five decades: a systematic review

AIMS

To Assess changes in infective endocarditis (IE) epidemiology over the last 5 decades.

METHODS AND RESULTS

We searched the published literature using PubMed, MEDLINE, and EMBASE from inception until December 2011.

DATA FROM

Einstein Medical Center, Philadelphia, PA were also included. Criteria for inclusion in this systematic review included studies with reported IE microbiology, IE definition, description of population studied, and time frame. Two authors independently extracted data and assessed manuscript quality. One hundred sixty studies (27,083 patients) met inclusion criteria. Among hospital-based studies (n=142; 23,606 patients) staphylococcal IE percentage increased over time, with coagulase-negative staphylococcus (CNS) increasing over each of the last 5 decades (p<0.001) and Staphylococcus aureus (SA) in the last decade (21% to 30%; p<0.05). Streptococcus viridans (SV) and culture negative (CN) IE frequency decreased over time (p<0.001), while enterococcal IE increased in the last decade (p<0.01). Patient age and male predominance increased over time as well. In subgroup analysis, SA frequency increased in North America, but not the rest of the world. This was due, in part, to an increase in intravenous drug abuse IE in North America (p<0.001). Among population-based studies (n=18; 3,477 patients) no significant changes were found.

CONCLUSION

Important changes occurred in IE epidemiology over the last half-century, especially in the last decade. Staphylococcal and enterococcal IE percentage increased while SV and CN IE decreased. Moreover, mean age at diagnosis increased together with male:female ratio. These changes should be considered at the time of decision-making in treatment of and prophylaxis for IE.

Profile of infective endocarditis observed from 2003 - 2010 in a single center in Italy

Background

This study aimed to provide a contemporary picture of the epidemiologic, clinical, microbiologic characteristics and in-hospital outcome of infective endocarditis (IE) observed in a single center in Italy.

Methods

We performed a retrospective study of patients with definite or probable IE observed at the “L. Sacco” Hospital in Milan, Italy, from January 1, 2003 through December 31, 2010.

Results

189 episodes of IE in 166 patients were included. The mean number of incident IE in the study period was of 1.27 (range 0.59-1.76) cases per 1000 patients admitted. The median age of the cohort was 57 (interquartile range, 43-72) years, 63% were male and 62.5% had native valve IE. Twenty-six percent were active intravenous drug users (IVDU), 29% had a health care-associated IE and 5% chronic rheumatic disease. Twenty-nine percent of the cases occurred in patients affected by chronic liver disease and 19% in HIV positive subjects. Staphylococcus aureus was the most common pathogen (30%), followed by streptococci. The mitral (34%) and aortic (31%) valves were involved most frequently. The following complications were common: stroke (19%), non-stroke embolizations (25%), heart failure (26%) and intracardiac abscess (9%). Surgical treatment was frequently employed (52%) but in hospital mortality remained high (17%). Health care-associated IE and complications were independently associated with an increased risk of in-hospital death, while surgery was associated with decreased mortality.

Conclusion

S. aureus emerged as the leading causative organism of IE in a University hospital in northern Italy. Our study confirmed the high in-hospital mortality of IE, particularly if health care associated, and the protective role of surgery.

[Initial patient assessment of infectious diseases and diagnostic steps with fever]

The initial assessment of patients with infectious diseases is challenging because of the extremely broad differential diagnosis as well as different host pathogen interactions influenced by a different immune status. The formal initial assessment, including the present and past medical history, thorough physical examination, clinical first impressions as well as routine laboratory analyses, is the basis of every preliminary diagnosis. Specific chief complaints have to be recognized in order to narrow down the differential diagnosis. In cases of life-threatening illnesses, such as septicemia, endocarditis, bacterial meningitis and severe pneumonia, the first diagnostic and therapeutic steps should be performed in a rapid sequence: bacterial blood samples, sputum and/or liquor samples are required and the initial antibiotic therapy has to be chosen empirically as the relevant bacterial spectrum related to the suspected illness must be covered. In less urgent cases it is recommended that a multi-step diagnostic approach be carried out which takes the differential diagnosis into account and prioritizes the probabilities. In the latter situation antibiotic treatment should be delayed to diagnose the infection correctly. Importantly, atypical courses must necessitate careful and critical reassessment of the diagnosis.

Infective endocarditis developing serious multiple complications

A 20-year-old female patient with no history of heart disease presented to the hospital with high fever, cough and sputum. On the third day of hospitalisation, left facial paralysis developed and cranial revealed an infarct in the right frontoparietotemporal lobe. Transthoracic echocardiography revealed 1.5 × 2 cm-sized vegetation on the mitral valve and severe mitral regurgitation. On the 11th day of hospitalisation, multiple emboli were shown to be present in the left iliac artery. Since the patient had recurrent septic emboli despite 3 weeks of treatment, a surgical intervention was planned. The vegetation was removed and the mitral valve was replaced by mechanical prostheses. During the postoperative period, acute renal failure developed in the patient. The treatment was completed in 6 weeks with full recovery. This case confirms that infective endocarditis may present with various clinical situations, and that a high index of suspicion and surgical intervention, in addition to aggressive antibiotic therapy, is lifesaving.

Tricuspid Endocarditis and Septic Pulmonary Embolism in an Intravenous Drug User with advanced HIV Infection

Cardiac complications are becoming increasingly important in patients with HIV infection. Right-sided endocarditis are more common in intravenous drug users (IVDU) with HIV infection. Some studies have pointed out that the clinical outcome of such patients depends on the affected valve referred to the responsible agent rather than the HIV serostatus. However, severe immunosupression and low CD(4) count are associated with increased risk of death. This report presents a case of isolated tricuspid valve endocarditis with advanced HIV infection who was also an IVDU.

Management of infective endocarditis: challenges and perspectives

Despite improvements in medical and surgical therapies, infective endocarditis is associated with poor prognosis and remains a therapeutic challenge. Many factors affect the outcome of this serious disease, including virulence of the microorganism, characteristics of the patients, presence of underlying disease, delays in diagnosis and treatment, surgical indications, and timing of surgery. We review the strengths and limitations of present therapeutic strategies and propose future directions for better management of endocarditis according to the most recent research. Novel perspectives on the management of endocarditis are emerging and offer hope for decreasing the rate of residual deaths by accelerating the process of diagnosis and risk stratification, reducing delays in starting antimicrobial therapy, rapid transfer of high-risk patients to specialised medico-surgical centres, development of new surgical methods, and close long-term follow-up.

Prospective study of infective endocarditis from a developing country

BACKGROUND

There has been a considerable change in the profile of infective endocarditis (IE) worldwide. However, prospective studies of IE from developing countries are rare.

AIM

The aim of this study was to evaluate predisposing factors, clinical presentation, echocardiography, microbiology, in-hospital course, and outcomes of patients with definite IE.

METHODS

This was a prospective observational study of consecutive cases of definite IE as per the modified Duke criteria.

RESULTS

Between 2004 and 2006, a total of 104 cases of definite IE were identified. The mean age was 23.5 years (interquartile range, 9-38 years), with a male preponderance (2.5:1). Congenital heart disease accounted for 39.4% cases of IE, followed by native valve disease (29.8%), prosthetic valve disease (20%), and normal valves (7.7%). Echocardiography was diagnostic in 96.7% of the patients. Positive cultures were obtained in only 41% of the cases, with staphylococci and streptococci being the most common organisms. Seventy-three percent of the cases had at least 1 major complication. Only 15% of the cases underwent surgery for IE. The in-hospital mortality was 26%. On multivariate analysis, an underlying heart disease other than native valve disease and septic shock were independent predictors of mortality.

CONCLUSION

The mean age of IE in India is significantly lower than that in the West. Unlike previous reports, congenital heart disease is the major predisposing factor. Culture positivity rates and surgery for IE are unacceptably low. In conclusion, IE in India is associated with a very high morbidity and mortality.