Infective endocarditis

Early fibrin biofilm development in cardiovascular infections

The single most common microbe causing cardiovascular infections is Staphylococcus aureus (S. aureus). S. aureus produces coagulase that converts fibrinogen to fibrin, which is incorporated into biofilms. This process aids in adherence to intravascular structures, defense against the host immune system, and resistance to antimicrobial treatment. Despite its significance, fibrin formation in S. aureus biofilms remains poorly understood. Therefore, this study aimed to elucidate the early development of cardiovascular biofilms. Clinically isolated coagulase-positive S. aureus and coagulase-negative Staphylococcus lugdunensis (S. lugdunensis) from patients with cardiovascular infections, and a coagulase mutant S. aureus Δcoa, were grown in tryptic soy broth (TSB), Iscove's Modified Dulbecco's Medium (IMDM), and pooled human plasma, with or without porcine heart valves. Bacterial growth, metabolic activity, and bacterial fibrinogen utilization were measured over 24 h at 37 °C. Time-lapse confocal microscopy was used to visualize and track biofilm development. S. aureus exhibited more growth in TSB and human plasma than S. lugdunensis and S. aureus Δcoa, but showed similar growth in IMDM after 24 h. Peak metabolic activity for all isolates was highest in TSB and lowest in human plasma. The presence of porcine valves caused strain-dependent alterations in time to peak metabolic activity. Confocal imaging revealed fibrin-based biofilm development exclusively in the coagulase-producing S. aureus strains. Between 2 and 6 h of biofilm development, 74.9 % (p = 0.034) of the fibrinogen from the medium was converted to fibrin. Variations in fibrin network porosity and density were observed among different coagulase-producing S. aureus strains. Fibrin formation is mediated by S. aureus coagulase and first strands occurred within 3 h for clinical strains after exposure to human plasma. This study stresses the importance of experimental design given the bacterial changes due to different media and substrates and provides insights into the early pathogenesis of S. aureus cardiovascular biofilms.

Predicting in-hospital mortality in infective endocarditis: insights from the Naples prognostic score

BACKGROUND

Infective Endocarditis (IE) is a severe and potentially life-threatening infection of the heart valves, necessitating a comprehensive understanding of factors influencing patient outcomes.

OBJECTIVE

The study aims to investigate the relationship between NPS and in-hospital mortality in patients diagnosed with Infective Endocarditis (IE).

METHODS

A total of 153 IE patients were included in the study, with 32 (20,9%) experiencing in-hospital mortality. Patients were categorised into survivors and non-survivors, and detailed clinical and demographic characteristics were recorded. The final endpoint of the study was determined as in-hospital mortality. Regression analyses were conducted to identify the independent variables, and Kaplan-Meier estimates were created to determine survival outcomes, using a significance level of p < 0.05 for all statistical analyses.

RESULTS

The non-survivor group exhibited a significantly higher NPS compared to the survivor group (28 (87.5) vs. 56 (46.3); p < 0.001). ROC curve analysis, utilising NPS, the neutrophil-to-lymphocyte ratio (NLR), the lymphocyte-to-monocyte ratio (LMR), albumin, and total cholesterol values, identified NPS as the most robust parameter, with an area under the curve of 0.704 (95% CI: 0.612-0.797; p < 0.001). Multivariate regression analysis revealed Septic shock (p = 0.001), NPS (p = 0.004), and Age (p = 0.012) as independent determinants of in-hospital mortality in IE patients.

CONCLUSIONS

This study demonstrated a strong correlation between NPS and mortality in IE. This novel score, as it reflects both the level of inflammation and nutrition, can be used to predict the prognosis in IE.

Safety and Efficacy of Outpatient Parenteral Antibiotic Therapy (OPAT) in Patients With Infective Endocarditis: A Systematic Review and Meta-Analysis

BACKGROUND

Infective endocarditis (IE) is a life-threatening infection requiring prolonged intravenous antimicrobial therapy. Outpatient parenteral antibiotic therapy (OPAT) has emerged as an alternative to prolonged hospitalization, but its safety and efficacy in IE remain debated.

HYPOTHESIS

This systematic review and meta-analysis aimed to evaluate the outcomes of OPAT in IE patients.

METHODS

We systematically searched MEDLINE, Cochrane CENTRAL, Google Scholar, and Scopus for studies assessing OPAT in IE. Eligible studies included randomized controlled trials and observational studies reporting at least one relevant outcome (mortality, relapse, readmission, valve surgery, and adverse events). Pooled estimates were calculated using a random-effects model, and heterogeneity was assessed using the I² statistic. Risk of bias was evaluated using the ROBINS-I tool.

RESULTS

A total of 25 studies involving 2654 patients were included in the analysis. Patients treated with OPAT had a mortality rate of 0% during the treatment period and 5% during follow-up. The readmission rate was 16% during the treatment period, 4% of the patients had relapse, while 16% of patients underwent cardiac surgery. During follow-up, the readmission rate was 19%, with a relapse rate of 2%, and 14% of patients underwent cardiac surgery. Sensitivity analyses did not significantly affect the results, highlighting the robustness of the findings.

CONCLUSION

OPAT appears to be safe and effective for IE patients, with low mortality and relapse rates. However, increased readmission rates and IV-line complications warrant careful patient selection and monitoring. Further prospective trials are needed to refine OPAT protocols.

3D Transesophageal echocardiography has benefits in the diagnosis and prognosis of patients with infectious endocarditis

Introduction Infective endocarditis (IE), despite advancements in diagnostic and therapeutic strategies, remains a life-threatening condition with high in-hospital mortality. The aim of this study was to assess an importance of a different echocardiographic techniques in the evaluation of patients with IE.MethodsThis prospective study included all consecutive patients hospitalized with a diagnosis of IE. Each patient underwent both 2D transesophageal echocardiography (2DTOE) and 3D transesophageal echocardiography (3DTOE) as part of the initial diagnostic evaluation. Laboratory results, isolated pathogens, and monitoring during hospitalization were also taken into account.ResultsThe study included 59 patients (69.49% male, mean age 64.4 ± 16.0). Native valve endocarditis (NVE) was present in 32 (54.24%), prosthetic valve endocarditis (PVE) in 17 (28.81%), and cardiac device-related IE (CDIE) in 10 (16.95%). Blood cultures were positive in 72.4% of cases, with Enterococcus faecalis predominant in NVE, and Staphylococcus species in PVE (S. epidermidis) and CDIE (S. aureus) (p = 0.039). TOE provided detailed imaging, detecting more lesions, with 3D TOE excelling in identifying destructive lesions, particularly perforations (p < 0.001). Vegetations were most frequent in NVE and CDIE, while destructive lesions were more common in PVE (p < 0.05). 3D TOE identified longer vegetations and more destructive lesions, especially in PVE (p < 0.05).Conclusion3D TOE, provide a detailed real time imaging, and could be considered as key adjunctive modality in practice when the cardiac anatomy is not precisely visualized by 2D TOE, particularly when advanced surgical planning is required.

The Dilemma of Surgical Timing in Acute Aortic Valve Endocarditis: Does Early Surgery Improve Risks or Prognosis?

BACKGROUND

Acute aortic valve infective endocarditis (IE) presents a critical surgical timing dilemma. This study investigates whether early surgical intervention (within seven days of targeted antibiotic therapy initiation) affects mortality and clinical outcomes compared to delayed/conventional surgery.

METHODS

A retrospective, multicenter analysis of 204 patients with aortic IE was conducted, excluding emergency cases requiring immediate intervention. Patients were stratified into EARLY (≤7 days) and LATE (>7 days) surgical groups. Primary endpoints included in-hospital mortality and major adverse events, while secondary endpoints assessed long-term survival, recurrence, and reintervention rates.

RESULTS

No significant differences in in-hospital mortality were observed between groups (16% in both). The LATE group exhibited a trend toward increased permanent pacemaker implantation (16% vs. 8.2%; p = 0.100) and a higher incidence of postoperative atrial fibrillation (36% vs. 24%, p = 0.048). Infective endocarditis recurrence and long-term survival did not significantly differ between groups. Predictors of one-year mortality included chronic kidney disease, annular abscess, extracorporeal membrane oxygenation (ECMO) use, and prolonged mechanical ventilation.

CONCLUSIONS

These findings suggest that early surgery, following a short course of antibiotics, does not compromise outcomes nor increase recurrence risk, challenging the conventional preference for delayed intervention in non-emergency IE cases.

The prognostic role of vegetation size in pediatric infective endocarditis: a retrospective study using decision curve and dose-response analysis

OBJECTIVE

To explore the predictive value of vegetation size on the prognosis of pediatric infective endocarditis (IE).

METHODS

A total of 27 children diagnosed with IE who were admitted to Kunming Children's Hospital from January 2014 to June 2024 were included. The good prognosis group comprised 10 cases, while the bad prognosis group comprised 17 cases. The receiver operating characteristic (ROC) curve, restricted cubic spline model, and decision curve analysis were utilized to assess the predictive value of vegetation size on the prognosis of pediatric IE.

RESULTS

There were statistically significant differences in vegetation size, hemoglobin, platelet count, and prothrombin time between the two groups (P < 0.05). The ROC curve demonstrated that vegetation size had a high predictive accuracy for the prognosis of pediatric IE (AUC = 0.841, 95% CI: 0.775-0.924). Decision curve analysis indicated that vegetation size held substantial clinical value for predicting the prognosis of pediatric IE. The restricted cubic spline analysis revealed a linear dose-response relationship between vegetation size and prognosis of pediatric IE (nonlinear test, P = 0.084).

CONCLUSION

Significant differences were observed in vegetation size, hemoglobin, platelet count, and prothrombin time between different prognosis of pediatric IE. Limited evidence indicates that vegetation size is a critical factor in predicting the prognosis of pediatric IE. However, studies with larger sample sizes are needed to confirm the accuracy of these conclusions.

A Case of Infective Endocarditis Caused by Beta-Lactam Resistant Streptococcus Alactolyticus

Background

Streptococcus alactolyticus is a rare cause of human infections, with limited reports of infective endocarditis (IE).

Case report

We present a case of a 68-year-old male with severe aortic stenosis who developed S. alactolyticus associated IE resistant to beta-lactams. Initial treatment with vancomycin and gentamicin led to temporary improvement, but the patient later developed complications, including splenic infarction and an aortic root abscess. Despite intensified antimicrobial therapy, he ultimately succumbed to multiorgan failure.

Conclusion

This case underscores the importance of early identification of resistant pathogens, appropriate antibiotic selection, and vigilant monitoring for complications. The rising incidence of beta-lactam resistance in streptococcal infections highlights the need for ongoing epidemiological surveillance and research to optimize treatment strategies.

LEARNING POINTS

Streptococcus alactolyticus is a rare but emerging cause of infective endocarditis that necessitates increased clinical awareness.

Simultaneous Periprosthetic Joint Infection and Infective Endocarditis: Prevalence, Risk Factors, and Clinical Presentation

BACKGROUND

Infective endocarditis (IE) and periprosthetic joint infections (PJI) occur due to hematogenous bacterial spread, theoretically increasing the risk for concurrent infections. There is a scarcity of literature investigating this specific association. We aimed to assess the prevalence, comorbidities, and clinical presentation of patients who have simultaneous PJI and IE.

METHODS

We retrospectively identified 655 patients (321 men, 334 women; 382 total hip arthroplasty, 273 total knee arthroplasty) who developed a PJI from July 1, 2015, to December 31, 2020, at one institution. There were two groups created: patients diagnosed with PJI with IE (PJI + IE) and PJI patients who did not have IE (PJI). We analyzed clinical outcomes and comorbidities.

RESULTS

There were nine patients who had PJI with IE (1.4% of PJI patients). The C-reactive protein (170.9 versus 78, P = 0.026), Elixhauser comorbidity score (P = 0.002), length of hospital stay (10.9 versus 5.7 days, P = 0.043), and the 2-year postdischarge mortality rate (55.6 versus 9.0%, P = 0.0007) were significantly greater in the PJI + IE group. Comorbidities such as iron deficiency anemia (P = 0.03), coagulopathy (P = 0.02), complicated diabetes mellitus (P = 0.02), electrolyte disorders (P = 0.01), neurologic disease (P = 0.004), paralysis (P = 0.04), renal failure (P = 0.0001), and valvular disease (P = 0.0008) occurred more frequently in the PJI + IE group. Modified Duke's criteria were met for possible or definite IE in eight of the nine patients.

CONCLUSIONS

Concurrent PJIs and IE, although rare, are a potentially devastating disease state with increased length of hospital stay and 2-year mortality rates. This emphasizes the need for appropriate IE workups in patients who have a PJI. The modified Duke's criteria are effective in establishing a diagnosis for IE in this scenario.

Mendelian Randomization Reveals No Causal Association Between Periodontitis and Infective Endocarditis

OBJECTIVES

Clarifying the uncertain causal relationship between periodontitis and infective endocarditis using Mendelian randomization analysis, given their historically perceived association and clinical significance.

METHODS

Genetic variation data for acute periodontitis, chronic periodontitis, aggressive periodontitis, and infective endocarditis were obtained from published GWAS in individuals of European ancestry. Instrumental variables significantly associated with periodontitis were selected and univariable Mendelian randomization was conducted to infer the causal association between periodontitis and infective endocarditis. Multivariable Mendelian randomization was also performed to adjust for potential confounders including smoking, drinking, diabetes, and education.

RESULTS

Our analysis found no evidence of a causal association between periodontitis and infective endocarditis, with odds ratios (ORs) of 0.992 (95% CI: 0.879-1.120), 0.947 (95% CI: 0.738-1.214), and 1.056 (95% CI: 0.916-1.217) for acute periodontitis, chronic periodontitis, aggressive periodontitis, respectively. The robustness of our findings was confirmed by heterogeneity tests, pleiotropy tests, leave-one-out analyses, and MR-PRESSO. In the multivariable MR analysis, adjusting for smoking, drinking, diabetes, and education, the overall patterns between genetic liability to periodontitis and infective endocarditis remained consistent (all P > .05).

CONCLUSION

Our findings indicate that there is no genetic causal association between periodontitis and infective endocarditis.

Prognostic factors for long-term mortality after surgery of left-sided infective endocarditis

BACKGROUND

Infective endocarditis has low prevalence but a high mortality rate. Left-sided infective endocarditis (LSIE) has a higher mortality rate than right-sided infective endocarditis. Surgical treatment is occasionally considered for LSIE; however, few data are available on the long-term prognostic factors for LSIE after surgical treatment. This study investigated the risk factors for long-term mortality in LSIE patients who underwent surgical treatment.

METHODS

This retrospective study enrolled adult patients with LSIE who were admitted to Severance Hospital in South Korea and underwent surgical treatment from November 2005 to August 2017. The primary outcome was risk factors for overall all-cause mortality. Multivariable Cox regression analysis was performed to identify risk factors for long-term mortality of patients with LSIE who received surgical treatment.

RESULTS

This study enrolled 239 with LSIE who underwent surgery. The median follow-up period was 75.9 months, and there were 34 deaths (14.2%) during the study period. Multivariable Cox analysis showed that central nervous system complications (hazard ratio [HR]: 3.55, 95% confidence interval [CI]: 1.76-7.17, P <  0.001), chronic liver disease (CLD) (HR: 4.33, 95% CI: 1.57-11.91, P =  0.005), and age ≥  65 years (HR: 2.65, 95% CI: 1.28-5.51, P =  0.009) were risk factors for overall mortality. Kaplan-Meier analysis indicated a significant difference in survival between patients with and without CNS complications (P <  0.001, log-rank).

CONCLUSION

Central nervous system complications, CLD, and older age were associated with long-term mortality in surgically treated patients with LSIE. Preventive strategies for CNS complications would improve the treatment of LSIE.

The Evolving Landscape of Infective Endocarditis: Difficult-to-Treat Resistance Bacteria and Novel Diagnostics at the Foreground

Infective endocarditis (IE) is a relatively rare but potentially life-threatening disease characterized by substantial mortality and long-term sequelae among the survivors. In recent decades, a dramatic change in the profile of patients diagnosed with IE has been observed primarily in developed countries, most likely due to an aging population and a recent increase in invasive medical procedures. Nowadays, the typical IE patient is usually older, with complex comorbidities, and a history significant for cardiac disease, including degenerative heart valve disease, prosthetic valves, or cardiovascular implantable electronic devices (CIEDs). Moreover, as patient risk factors change, predisposing them to more healthcare-associated IE, the microbiology of IE is also shifting; there are growing concerns regarding the rise in the incidence of IE caused by difficult-to-treat resistance (DTR) bacteria in at-risk patients with frequent healthcare contact. The present review aims to explore the evolving landscape of IE and summarize the current knowledge on novel diagnostics to ensure timely diagnosis and outline optimal therapy for DTR bacterial IE.

Surgical treatment for infectious endocarditis in China

This important topic of infectious endocarditis (IE) has been covered previously with large multicenter studies and reviews of national databases, most of which come from developed countries. While studies on IE in developing countries such as China are rare, a study of IE undergoing cardiac surgery in China was conducted to investigate retrospective risk factors for hospital mortality of cardiac surgery for IE. This study of patients with IE receiving cardiac surgery in the research period at our medical center was performed retrospectively; 896 patients were assigned to the hospital mortality group (n = 48) and none hospital mortality group (n = 848). Forty-eight operative deaths (5.4%) occurred. Binary logistic regression analysis for independent risk factors for hospital mortality indicated that neurological complications preoperative, destructive annulus, preoperative mitral insufficiency, postoperative left ventricular ejection fractions, and paravalvular leak are related to hospital mortality (all P < .001). We identified modifiable risk factors for hospital mortality of cardiac surgery for IE. Early and timely diagnosis and surgery, advancement of surgical techniques, and excellent cardiac protection may decrease hospital mortality for IE.

Aortic Valve Endocarditis in an Intravenous Drug User With Psychiatric History: A Diagnostic Challenge

Infective endocarditis (IE), a life-threatening cardiac infection, can present atypically, complicating diagnosis. We present a case of a 45-year-old male patient with schizophrenia and intravenous drug use (IVDU) who presented with suicidal ideation. Though afebrile, he exhibited tachycardia, bilateral pedal edema, bronchial breath sounds, and a diastolic murmur. Echocardiography identified an extensive aortic valve vegetation and a reduced ejection fraction. Despite negative resected valve cultures and Gram staining, emergency aortic valve replacement and left atrial appendage clipping were performed, followed by a six-week antibiotic course. This case underscores the diagnostic challenge of afebrile, culture-negative IE, likely due to prior antibiotics or fastidious organisms, particularly in high-risk populations like those with IVDU. Psychiatric presentations may obscure typical IE symptoms, necessitating heightened clinical suspicion and comprehensive evaluation, including echocardiography, even without classic signs like fever or leukocytosis. Timely intervention and individualized diagnostics are critical to improving outcomes in such complex cases.

[18F]FDG PET/CT in cardiovascular infections: a practical approach

Cardiovascular infections have a high mortality rate requiring prompt diagnosis and timely management. [18F]fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) has emerged as a valuable diagnostic imaging modality for various cardiovascular infections, including infective endocarditis (IE) and cardiac implantable electronic device (CIED) infections, particularly when the diagnosis remains challenging. In this article, we provide an overview of the epidemiology and clinical presentation of IE and CIED-related infections, the indications for 18F-FDG-PET/CT and its incremental role in establishing diagnosis as well as illustrate a variety of clinical cases and discuss interpretation criteria.

Current trends and challenges in infective endocarditis

PURPOSE OF REVIEW

Infective endocarditis (IE) is a complex disease with increasing global incidence. This review explores recent trends in IE infection patterns, including healthcare-associated IE (HAIE), drug-use-associated IE (DUA-IE), multidrug-resistant organisms (MDROs), and challenges in managing prosthetic valve and device-related infections.

RECENT FINDINGS

Staphylococcus aureus has emerged as the leading cause of IE, especially in HAIE and DUA-IE cases. Increasingly prevalent MDROs, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, pose further clinical challenges. Advances in molecular diagnostics have improved the detection of culture-negative endocarditis. The introduction of the AngioVAC percutaneous aspiration device promises to change the management of right and possibly some left sided IE. Multidisciplinary team management and early surgery have demonstrated improved outcomes including partnerships with psychiatry and addictions services for those with intravenous DUA-IE.

SUMMARY

IE presents significant diagnostic and therapeutic challenges due to evolving infection patterns, MDROs, and HAIE. Early diagnosis using advanced imaging, appropriate early antimicrobial therapy, and multidisciplinary care, including timely surgery, are critical for optimizing patient outcomes.

Bacterial species with different nanocolony morphologies have distinct flow-dependent colonization behaviors

Fluid flows are dominant features of many bacterial environments, and flow can often impact bacterial behaviors in unexpected ways. For example, the most common type of cardiovascular infection is heart valve colonization by gram-positive bacteria like Staphylococcus aureus and Enterococcus faecalis (endocarditis). This behavior is counterintuitive because heart valves experience high shear rates that would naively be expected to reduce colonization. To determine whether these bacteria preferentially colonize higher shear rate environments, we developed a microfluidic system to quantify the effect of flow conditions on the colonization of S. aureus and E. faecalis. We find that the preferential colonization in high flow of both species is not specific to heart valves and can be found in simple configurations lacking any host factors. This behavior enables bacteria that are outcompeted in low flow to dominate in high flow. Surprisingly, experimental and computational studies reveal that the two species achieve this behavior via distinct mechanisms. S. aureus grows in cell clusters and produces a dispersal signal whose transport is affected by shear rate. Meanwhile, E. faecalis grows in linear chains whose mechanical properties result in less dispersal in the presence of higher shear force. In addition to establishing two divergent mechanisms by which these bacteria each preferentially colonize high-flow environments, our findings highlight the importance of understanding bacterial behaviors at the level of collective interactions among cells. These results suggest that distinct multicellular nanocolony morphologies have previously unappreciated costs and benefits in different environments, like those introduced by fluid flow.

Efficacy and safety of mechanical thrombectomy in acute ischaemic stroke secondary to infective endocarditis

OBJECTIVES

Acute ischaemic strokes (stroke) are frequent and severe extracardiac complications in infective endocarditis (IE). Because intravenous thrombolysis (i.v.-thrombolysis) is contraindicated, mechanical thrombectomy (thrombectomy) offers potential benefits. We aimed to compare thrombectomy efficacy and safety between IE-related and general stroke cases.

METHODS

Multicentre study of consecutive IE cases treated with thrombectomy at nine stroke centres in Spain from 2011 to 2022. Using propensity score matching, 50 IE cases were 1:4 matched with patients without IE stroke (n = 200). Efficacy was defined by successful recanalization rates (modified treatment in cerebral ischaemia scale ≥2 b), neurological improvement at 24 hours (decrease of National Institutes of Health Stroke Scale compared with baseline), and good neurological outcome rates at 3 months (modified Rankin scale ≤2). Safety was assessed by intracranial haemorrhage (IC-haemorrhage), symptomatic IC-haemorrhage, crude mortality, and stroke-related mortality.

RESULTS

Among 54 IE cases, 50 were matched with 200 controls. Successful recanalization was similarly achieved in both groups (76% vs. 83%). Median National Institutes of Health Stroke Scale at 24 hours was comparable, with analogous rates of neurological improvement (78% vs. 78%), and early dramatic response (48% vs. 46.5%). No differences were seen regarding IC-haemorrhage rates, except for when prior i.v.-thrombolysis was given. Although crude mortality was higher in the IE cohort, no differences were seen in stroke-related mortality (12% vs. 15%). At 3 months, modified Rankin scale scores of the two groups were superimposable.

DISCUSSION

Thrombectomy in IE is as effective and safe as in patients without IE, and prior i.v.-thrombolysis could decrease the procedural safety. Clinical practice guidelines may consider including the recommendation to perform thrombectomy alone in IE-related stroke.

A Population-Based Cohort Study on the Association Between Oral Third-Generation Cephalosporins and Other Antimicrobial Prescriptions and Adverse Events: Findings From the Shizuoka Kokuho Database Study

INTRODUCTION

The rise of drug-resistant bacteria and associated adverse events have been linked to inappropriate antibiotic use. In Japan, inappropriate prescriptions of oral antimicrobials might be prevalent and contribute to this issue. This study explored the association between oral third-generation cephalosporins and other antimicrobials with adverse events in the Japanese population.

METHODS

We conducted a population-based cohort study using a large-scale database, i.e., the Shizuoka Kokuho Database. This study included individuals with health checkup records, with the observation period for each participant ranging from insurance enrollment or April 2012 to insurance withdrawal or September 2020. The primary outcome was hospitalization with clinically important antibiotic-related adverse events (ciArAEs) based on the International Classification of Diseases, Tenth Revision (ICD-10) codes. In addition, we executed a multivariable analysis employing potential predictive factors selected from comorbidities, prescribed antimicrobials, and health checkup results.

RESULTS

Of the 685,161 individuals included in the analysis, 2,557 had ciArAEs. Third-generation cephalosporins (HR: 1.14, 95% CI: 1.01-1.29), tetracyclines (HR: 2.14, 95% CI: 1.47-3.13), and aminoglycosides (HR: 8.36, 95% CI: 1.18-59.2) were identified as potential predictive factors for ciArAEs among oral antimicrobial agents. Additional predictive factors included older age, males, intravenous penicillin, and various comorbidities.

CONCLUSIONS

By utilizing a large-scale database, we demonstrated the relationship between the use of antimicrobial agents, including oral third-generation cephalosporins, and ciArAEs. This finding underscores the need for enhanced prescription practices and further antimicrobial resistance and adverse events studies.

A Rare Case of Ventricular Septal Defect and Double-Chambered Right Ventricle With Bilateral Cardiac Infective Endocarditis

Infective endocarditis (IE) typically affects the left side of the heart. Multiple valve involvement on both sides of the heart is a rare occurrence. However, congenital heart defects, particularly ventricular septal defects (VSD), can predispose individuals to bilateral endocarditis. We present a case of a 41-year-old patient with congenital VSD and double-chambered right ventricle (DCRV) who presented with fever, generalized fatigue, and unintentional weight loss of 20 kg over two months. Transthoracic echocardiography revealed vegetations on the aortic valve, pulmonary valve, and right ventricular outflow tract (RVOT), alongside a small VSD with left-to-right shunt. The blood cultures revealed Streptococcus mutans. Initially, the patient was treated with intravenous antibiotics. In the further course, she showed persistent symptoms and signs of sepsis and failure of vegetation regression. The decision was made for surgical intervention. The aortic valve was replaced with a mechanical valve (St. Jude Medical Regent, 23 mm, Saint Paul, Minnesota, United States), and the pulmonary valve was replaced with a tissue valve (Medtronic Freestyle, 27 mm, Minneapolis, Minnesota, United States). The VSD was closed directly, and the fibromuscular tissue causing DCRV was resected. The postoperative recovery was uneventful, and the patient was discharged in stable general condition. This case emphasizes the importance of considering congenital heart defects in patients with bilateral endocarditis, highlighting the need for comprehensive preoperative echocardiographic evaluation and intraoperative assessment. Endocarditis prophylaxis should be strongly considered for patients with intracardiac shunts, particularly during dental procedures involving the disturbance of the gingival tissue, the periapical region of teeth, or the oral mucosa.

First-In-Human Study of [64Cu]Cu-DOTATATE PET/CT in Infective Endocarditis: A Prospective Head-to-Head Comparison With [18F]FDG

BACKGROUND

Infective endocarditis (IE) can be challenging to diagnose. Positron emission tomography/computed tomography (PET/CT) with 2-deoxy-2-[18F]-fluoro-d-glucose ([18F]FDG) is recommended as a diagnostic tool in the guidelines, but holds limitations. The aim of this study was to compare the tracer uptake between the novel [64Cu]Cu-DOTATATE, which has low cardiac uptake and does not require fasting or dietary restrictions, and [18F]FDG in patients with IE and examine the sensitivity and specificity.

METHODS

The CuDOS study (Cu-Dotatate Positron Emissions Tomography in Infective Endocarditis) was a prospective study including 20 patients with IE (10 with prosthetic valve endocarditis and 10 with native valve endocarditis) and 20 controls. All participants underwent [64Cu]Cu-DOTATATE and [18F]FDG PET/CT. Scans were read blinded to clinical data. Tracer uptakes were measured as maximum standardized uptake values in each heart valve. Differences were tested with Wilcoxon rank tests.

RESULTS

The median age of the cases and controls was 68 years (interquartile range [IQR], 55.0-75.5) and 61 years (IQR, 57.0-69.5), respectively. [64Cu]Cu-DOTATATE uptake (median maximum standardized uptake value [IQR]) in patients with IE was higher than in controls (2.34 [1.40-3.23] versus 1.44 [1.21-1.60]; P =0.008), although this difference was mainly driven by prosthetic valve endocarditis cases (3.23 [2.02-3.86]; P <0.001) and not between native valve endocarditis cases and controls (1.51 [1.23-2.58]; P=0.428). The sensitivity of [64Cu]Cu-DOTATATE and [18F]FDG PET/CT in 20 cases versus 20 controls were equal, and the specificity was 90% and 75%, respectively. The analysis of prosthetic valve endocarditis versus the 20 controls showed equal sensitivity (80%), and a specificity of 90% and 75%, respectively (P =0.38). In addition, a greater proportion of scans achieved diagnostic certainty with [64Cu]Cu-DOTATATE PET/CT compared with [18F]FDG PET/CT for native valve endocarditis, prosthetic valve endocarditis, and controls.

CONCLUSIONS

[64Cu]Cu-DOTATATE PET/CT showed uptake in the infected valve in patients with IE, and has major advantage as it does not require any preparation compared with [18F]FDG. [64Cu]Cu-DOTATATE had a numerically higher specificity than [18F]FDG, although the difference was not statistically significant. Both tracers were limited in the detection of native valve endocarditis.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05432427. www.clinicaltrialsregister.eu; Unique identifier: 2021-005501-27.

Bacterial Diversity in Native Heart Valves in Infective Endocarditis

Background: Infective endocarditis (IE) is an infectious disease caused by the hematogenous dissemination of bacteria into heart valves. Improving the identification of pathogens that cause IE is important to increase the effectiveness of its therapy and reduce the mortality caused by this pathology. Methods: Ten native heart valves obtained from IE patients undergoing heart valve replacements were analyzed. Bacterial invasion in the heart valves was studied by Gram staining of histological sections. Histopathological changes accompanied with bacterial invasion were studied by immunohistochemical analysis of pan-leukocyte marker CD45, platelet marker CD41, and neutrophil myeloperoxidase. The taxonomic diversity of the bacteria was analyzed using 16S rRNA metabarcoding. Results: Gram staining of the histological sections revealed bacterial cells localized on the atrial surface at the leaflet's free edge or on the ventricular surface at the leaflet's base within fibrin deposits in only three of the studied heart valves. Bacterial colonies were co-localized with microthrombi (CD41+ cells) containing single leucocytes (CD45+ cells), represented by segmented neutrophils. As a result of 16S rRNA metabarcoding, we detected the following bacterial genera: Pseudomonas (70% of the studied heart valves), Roseateles (60%), Acinetobacter (40%), Sphingomonas (40%), Enterococcus (30%), Reyranella (20%), Sphingobium (20%), Streptococcus (20%), Agrobacterium (20%), Ralstonia (10%), and Bacillus (10%). Conclusions: A number of opportunistic microorganisms that could not be detected by routine laboratory tests and were not eliminated during antibiotic therapy were identified in the IE-affected heart valves. The obtained results show the importance of 16S rRNA metabarcoding of heart valves removed due to IE not only as an independent diagnostic method but also as a highly accurate approach that complements routine tests for pathogen identification.

Invasion of pancreatic ductal epithelial cells by Enterococcus faecalis is mediated by fibronectin and enterococcal fibronectin-binding protein A

The poor prognosis of pancreatic cancer is often attributed to difficulties of early detection due to a lack of appropriate risk factors. Previously, we demonstrated the presence of Enterococcus faecalis (E. faecalis) in pancreatic juice and tissues obtained from patients with cancers of the duodeno-pancreato-biliary region, suggesting the possible involvement of this bacterial species in chronic and malignant pancreatic diseases. However, it remains unclear if and how E. faecalis can infect pancreatic ductal cells. In this study, we used immortalized normal human pancreatic ductal epithelial cells (iPDECs) and pancreatic ductal cancer cell lines to demonstrate that E. faecalis adheres to and invades pancreatic ductal lineage epithelial cells. Inhibitors of micropinocytosis or clathrin- or caveolae-mediated endocytosis suppressed iPDEC invasion by E. faecalis. Mechanistically, bacterial expression of enterococcal fibronectin-binding protein A (EfbA) was correlated with adhesive potential of E. faecalis strains. Knockout of fibronectin 1, a binding partner of EfbA, in iPDECs resulted in suppressed E. faecalis adhesion and invasion, suggesting the importance of the EfbA-fibronectin axis in infection of pancreatic ductal epithelial lineage cells. Overall, these results suggest that E. faecalis can colonize pancreatic tissue by infecting iPDECs, at least in part, via the expression of the cell adhesion factor EfbA.

Comparisons of Risk Scores for Infective Endocarditis Surgery: A Meta-Analysis

While multiple scoring systems exist to predict mortality in cardiac surgery, their utility in infective endocarditis (IE) remains uncertain, prompting this study to compare their prognostic accuracy. We conducted a comprehensive review using Ovid Medline, Embase, and Cochrane Central Register of Controlled Trials. Data were pooled using Open-Meta[Analyst] software, and calibration analysis was performed with Review Manager 5.4. Among 620 articles identified, 570 were screened, leading to 15 included studies. Twelve risk scores were analyzed for operative mortality discrimination in IE surgery, with the area under the curve (AUC) ranging from 0.64 to 0.83. Among the IE-specific risk scores, AUCs (95% confidence interval) were highest for ANCLA (Anemia, NYHA class IV, critical state, large intracardiac destruction, surgery on thoracic aorta) 0.838 (0.803-0.873), AEPEI (Association pour l'Etude et la Prevention de l'Endocadite Infectieuse) 0.764 (0.726-0.802), RISK-E (Risk Endocarditis) (0.752 (0.662-0.842) and APORTEI (Análisis de los factores PROnósticos en el Tratamiento quirúrgico de la Endocarditis Infecciosa) 0.750 (0.726-0.774) scores. Regarding traditional risk scores, EuroSCORE II performed at 0.750 (0.725-0.775) but underestimated mortality compared with EuroSCORE I in calibration analysis. In conclusion, EuroSCORE II and several endocarditis-specific scores had moderate discrimination (AUC > 0.75) in predicting mortality after IE surgery.

Association between serum bicarbonate and 28-day mortality in critically ill patients with infective endocarditis: a cohort study from MIMIC-IV

The relationship between bicarbonate level and mortality in critically sick patients with infective endocarditis (IE) is currently not well established. The MIMIC-IV database was used to provide data for a retrospective cohort research. Included were patients with IE who were hospitalized to the critical care unit (ICU). Within the first 24 h following ICU admission, the serum bicarbonate was assessed. The 28-day mortality was the end-point result. To evaluate the relationship between the serum bicarbonate and 28-day mortality, multivariable Cox regression was employed. The study included 450 patients with IE in serious condition in the ICU, with a 57.4-year-old average and 64.2% male representation. The 28-day mortality rate stood at 20%. Unadjusted analysis revealed that higher serum bicarbonate levels upon ICU admission were significantly linked to reduced 28-day mortality (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.85-0.95; p < 0.001). This correlation remained significant after adjusting for potential confounding factors (adjusted HR, 0.94; 95% CI 0.89-0.99; p = 0.028). When categorizing bicarbonate levels, patients in the highest group (T3, ≥ 25 mEq/L) showed a significantly decreased adjusted HR of 0.55 (95% CI 0.33-0.93; p < 0.001) in relation to the control group (T1, ≤ 22 mEq/L) in the final model. Consistent results were observed in subgroup analyses across various groups. In patients with IE in the ICU, elevated serum bicarbonate upon admission was independently linked to a lower 28-day mortality. These findings indicate that serum bicarbonate can serve as a prognostic marker, supporting the process of risk assessment and providing direction for the clinical care of patients with IE.

Bilateral Multivalvular Infective Endocarditis Presenting as a Splenic Infarction and Acute Ischemic Stroke in a Young Immunocompetent Woman

Bilateral multivalvular infective endocarditis (MIE) involving two or more cardiac valves of both the left and right sides of the heart is an extremely rare disease with a high mortality rate. We present a rare case of left- and right-sided MIE caused by Streptococcus mitis/oralis in a 36-year-old immunocompetent woman. The patient, with a past medical history of heart murmur since childhood, presented with left upper quadrant (LUQ) pain, fever, and chills. In the emergency department (ED), the patient's mental status deteriorated. On a physical examination, a holosystolic heart murmur was heard at the apex. The abdomen was tender in the LUQ. Neurological examination showed new right lower and upper extremity weakness. Laboratory results were significant for neutrophilic leukocytosis. The electrocardiogram (EKG) showed the right bundle branch block. Chest computed tomography (CT) of the abdomen and pelvis revealed splenomegaly with a splenic infarct. Magnetic resonance imaging (MRI) of the brain showed acute ischemic infarction of the left middle cerebral artery distribution. The patient underwent a mechanical thrombectomy. A repeat MRI of the brain showed a hemorrhagic conversion; thus, the patient was on hemicrania watch for five days. Transthoracic echocardiography (TTE) revealed left- and right-sided infective endocarditis (IE) with mobile 14 mm and 20 mm vegetations on the mitral and tricuspid valves and a left-to-right shunt through a patent foramen ovale (PFO). Blood culture grew Streptococcus mitis/oralis. Six-week antibiotic therapy was initiated. Surgical intervention for infective endocarditis was recommended, and the patient was transferred to the tertiary center for valve replacement surgery. However, the patient refused surgery despite understanding the risks and decided to return to her home country. In conclusion, bilateral multivalvular infective endocarditis is a rare and complex condition with a high burden of complications. This case underscores the importance of early diagnosis, prompt initiation of antimicrobial therapy, and timely surgical intervention to optimize outcomes.

Clinical suspicion and empirical treatment of infective endocarditis on hospital admission - a population-based cohort study

INTRODUCTION

Infective endocarditis (IE) is a challenging diagnosis to suspect and to confirm. The purpose of this study was to clarify how often IE is suspected already on hospital admission, which clinical signs trigger the physicians' suspicions and to investigate if the empirical treatment is adequate.

METHODS

A retrospective observational study of cases with definitive IE, during 2018-2019 in Skåne Region, Sweden was performed. Cases were identified by ICD-codes for IE and medical records were reviewed to reveal if IE was suspected at hospital admission and if empirical treatment was adequate.

RESULTS

Of 156 episodes with definitive IE, suspicion of IE arose on admission in 36 (23%) of the cases. A longer symptom duration, heart murmurs, male sex, and lower age were significantly more common in the group where IE was suspected. In the 118 cases where empirical antibiotic treatment was initiated, 98 (83%) got an adequate empirical treatment while in 16 (14%) of the cases the organism identified was resistant. IE-directed treatment was achieved significantly earlier in the suspicion group, median of 1 day, compared to a median of 2 days (p < 0.0001) when endocarditis was not initially suspected.

CONCLUSION

IE is suspected already upon admission mainly in cases with a subacute presentation. Increased knowledge of IE with acute presentation could possibly result in earlier diagnosis and correct IE-directed treatment. The clinical impact of this is uncertain since most cases still were treated with adequate empirical antibiotics.

A rare case of culture-negative infective endocarditis following cataract surgery

A 70-year-old man developed intermittent fever with chills, severe anorexia, generalized weakness, and mild exertional difficulty in breathing following posterior chamber intraocular lens replacement surgery for a mature white cataract in the left eye. Laboratory tests revealed persistent negative blood cultures, normocytic and normochromic anemia, neutrophilia, and elevated inflammatory markers despite multiple courses of antibiotics. All other investigations conducted to identify the cause of prolonged fever, including transthoracic echocardiography, were negative. However, transesophageal echocardiography detected an aortic valve vegetation. The patient had no history of valvular disease or any predisposing condition for infective endocarditis. The bacteremia was strongly suspected to have resulted from cataract surgery, although no obvious signs of eye infection were observed during the postoperative period. The patient was treated with empirical antibiotics, including vancomycin and ceftriaxone, which led to significant improvement. Because infective endocarditis remains a significant public health concern with increasing incidence rates, we present this unusual case of culture-negative infective endocarditis following cataract surgery, highlighting the diagnostic and therapeutic challenges encountered.

Antibiotic prophylaxis for patients undergoing dental care: a multi-centre evaluation in community and hospital dental services

Background Infective endocarditis (IE) is a life-threatening condition known to be associated with transient bacteraemia, the source of which can be the oral cavity. Scottish Dental Clinical Effectiveness Programme (SDCEP) 2018 implementation advice was introduced to provide practical guidance on National Institute for Health and Care Excellence Clinical Guideline 64 (2016) for management of patients at risk of IE undergoing dental treatment.Aims To assess current compliance with SDCEP's Antibiotic prophylaxis against infective endocarditis in six UK special care dentistry services.Method Four specific standards were set based on current guidance. Retrospective data were collected (from 01/01/2019 to 01/04/23) across six special care dentistry services in the UK, with an aim of 50 episodes of antibiotic prophylaxis (AP) in each service.Results In total, 248 episodes of care were included from dental services in London, East Surrey, Birmingham, Newcastle and North East England, Greater Glasgow and Clyde, and Newport (Wales). In 78% of episodes of care (n = 193), AP was administered to patients within SDCEP's special consideration sub-group. Additionally, 91% of patients outside the SDCEP sub-group had a justified reason recorded for AP. In all but three cases (99%), patients had an invasive dental procedure following AP. In 92% of cases, antibiotics were administered as per SDCEP 2018 advice.Conclusion Even with national implementation advice, this evaluation demonstrates inconsistencies in provision of AP throughout the UK. Practitioners prescribing and administering AP should remain aware of the changing aetiology of IE, as well as the reasons for and against prophylaxis, so that patients can make an informed decision.

Complicated infective endocarditis of the bioprosthetic mitral valve following the transcatheter mitral valve-in-valve procedure: a case report and literature review

Background

Since the transcatheter valve-in-valve (ViV) procedure was introduced in 2007, a few cases of infective endocarditis (IE) following the ViV procedure have been reported, which can be predisposed by older age, pre-existing medical conditions, and procedural techniques. Paravalvular abscesses constitute a rare complication of IE, resulting from extending IE beyond the valve annulus, less commonly caused by Klebsiella species. This complication is more common in prosthetic valves, particularly bioprosthetic valves.

Case summary

We describe a 75-year-old woman with Churg-Strauss syndrome and diabetes mellitus who underwent surgical replacement of bioprosthetic aortic and mitral valves 11 years ago. One year ago, she had a transcatheter mitral ViV procedure due to bioprosthetic mitral valve degeneration. The patient was referred to our centre with fatigue and fever, alongside elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein. Blood and urine cultures tested positive for Klebsiella oxytoca. Echocardiographic assessments revealed a paravalvular abscess (13 × 8 mm) in the posterolateral side of the bioprosthetic mitral valve, fistulized into the left ventricle. The patient received treatment with vancomycin, meropenem, and colistin and was a candidate for surgery. Eleven days after the patient's admission, she passed away.

Discussion

This study underscores the novelty of IE complicated with paravalvular abscess following the ViV procedure. In such cases, a multidisciplinary approach and timely surgical interventions are crucial for optimal patient outcomes.

A Rare Presentation of Infective Endocarditis Caused by Streptococcus gordonii Following Transcatheter Aortic Valve Replacement

Infective endocarditis (IE) is an infection of the heart endothelium as well as the heart valve with high mortality rate. The most common cause of infective endocarditis is Staphylococcus aureus. However, IE may be caused by various microorganism depending on the patient risk factor. One of the most important risk factors is the prosthetic heart valve. Patients after transcatheter aortic valve replacement (TAVR) are at risk of IE. The most common organisms to cause IE in TAVR patients are Enterococcus, Staphylococcus aureus, and coagulase-negative staphylococci. The presentation of IE in patients after TAVR is atypical and the conventional ways to diagnose IE have low sensitivity. Therefore the clinician should have high clinical suspicion for it. Herein, we discuss a rare case of infective endocarditis caused by Streptococcus gordonii in a patient who recently underwent TAVR.

Pathogenic spectrum of infective endocarditis and analysis of prognostic risk factors following surgical treatment in a tertiary hospital in China

BACKGROUND

This study aimed to summarize the pathogenic spectrum of infective endocarditis (IE) and analyze the risk factors for poor prognosis in surgical patients in a tertiary hospital in China.

METHODS

We retrospectively included patients diagnosed with IE between January 2013 and January 2022. The pathogenic spectrum was summarized; the risk factors for early postoperative mortality and embolic events were analyzed using multivariate logistic regression.

RESULTS

Among 630 patients who underwent blood cultures, the positivity rate was 56.83%. The most prevalent pathogens were viridans streptococci, Staphylococcus aureus, enterococci, and coagulase-negative staphylococci (CoNS). The prevalence of viridans streptococci significantly increased in the surgically treated group, compared to the medically treated group (50.80% vs. 27.78%, P < 0.001), while that of CoNS decreased (5.60% vs. 12.04%, P = 0.034). There has been a declining trend in the blood culture positivity in recent years compared to earlier years (2018-2022 vs. 2013-2017 = 60.95% vs. 47.30%, P = 0.037), with an increasing trend in viridans streptococci and a decreasing trend in CoNS. Multivariate logistic regression analysis identified male gender, coronary artery disease, platelet count < 100 × 109/L, albumin < 35 g/L, elevated creatinine, and prosthetic valve as independent risk factors for early postoperative mortality. Risk factors for embolic events included recent cerebral infarction within 3 months, history of peripheral vasculopathy, and hemoglobin (Hb) < 90 g/L.

CONCLUSIONS

Viridans streptococci predominates as the most common IE pathogen, with its incidence rising recently, especially among surgical patients. Blood culture positivity is decreasing. Understanding risk factors for early postoperative mortality and embolic events is crucial for optimizing patient management and prognosis.

CLINICAL TRIAL NUMBER

Not applicable.

Epidemiology of valvular heart disease in France

BACKGROUND

Demographic changes and improvements in the diagnosis and treatment of valvular heart diseases (VHDs) have led to changes in its epidemiological profile.

AIMS

To describe the epidemiology of VHD in France in 2022.

METHODS

Adults hospitalized due to VHD in 2022 were identified from the French National Health Data System and categorized by type of VHD on the basis of hospital diagnoses and interventions. Incidence and prevalence rates were calculated using national French demographic data.

RESULTS

In 2022, 51,894 adults (60.1% men) were hospitalized for VHD (97.0/100,000 inhabitants). The most frequently observed hospitalized VHDs were AS (61.6%) and MR (23.2%). The mean age at hospitalization was 74.0years, and this was higher for AS than MR (77.3 vs 71.2years). Infectious endocarditis was managed during the index hospitalization in 13.3% of patients. During the index hospitalization and the following 6months, 75.0% of patients underwent valve repair or replacement. Among hospitalized patients with AS, 56.9% had transcatheter aortic valve implantation and 24.9% had surgical aortic valve replacement. Among patients hospitalized for MR, 27.1% underwent surgical mitral valve repair, 12.7% transcatheter mitral valve repair and 19.1% mitral valve replacement. The all-cause death rate 1year after hospitalization for VHD was 13.7%. Overall, in France, on 1 January 2023, 1.90% of the adult population had VHD (2.08% of men and 1.72% of women). Overall, 363,574 had aortic stenosis (AS) and 409,570 had mitral regurgitation (MR).

CONCLUSION

VHDs are a major burden in France, particularly degenerative valve diseases of the left heart in older adults.

Nucleus-Targeting Photosensitizers Enhance Neutrophil Extracellular Traps for Efficient Eradication of Multidrug-Resistant Bacterial Infections

Neutrophil extracellular traps (NETs) are web-like complexes of DNA and proteins that are extruded by activated neutrophils and play critical roles as major components of the innate immune response against pathogen invasion. However, some microbes have developed strategies to evade NET attacks, leading to impaired immune defenses and persistent infections. In this study, an engineered neutrophil strategy for enhancing the antibacterial activity of NETs is developed. A nucleus-targeting photosensitizer (NCP) with strong reactive oxygen species production and a strong DNA-binding capacity is synthesized. NCP-loaded neutrophils are subsequently constructed via direct incubation of NCP with neutrophils, and the NCP is closely inserted into the nucleus DNA. Upon activation by bacteria-related toxins, NCP-coupled NETs can be released rapidly, actively trapping bacteria and providing a high local concentration of NCP around them. Both in vitro and in vivo results revealed that NCP-coupled NETs can effectively eradicate various multidrug-resistant bacteria and biofilms through photodynamic therapy, overcome bacterial immune evasion, and promote tissue recovery from severe wound infections. This design can significantly strengthen NET function, providing a non-antibiotic alternative platform for treating bacterial infectious diseases.

Non-linear relationship between platelet count and 28-day mortality in critically ill patients with infective endocarditis: a retrospective cohort study from MIMIC IV database

Background

The relationship between platelet count and 28-day mortality in critically ill patients with infective endocarditis (IE) is currently not well established.

Objective

This study aims to investigate the impact of platelet count on 28-day mortality in critically ill patients with infective endocarditis.

Methods

A retrospective cohort study was conducted involving 450 participants diagnosed with infective endocarditis and admitted to intensive care units (ICU). Vital signs, laboratory parameters and comorbidity were collected for all participants to analyze the association between platelet count and 28-day mortality. In order to assess the independent association between platelet count and 28-day mortality, we employed multivariable cox hazard regression analyses and smooth curve fitting. A further analysis was conducted using a two-piecewise linear regression model to examine the nonlinear association between platelet count and in-hospital mortality.

Results

A total of 450 critically ill patients with infective endocarditis were included in the study. The mean age was 57.4 years, and 64.2% were male. The overall 28-day mortality rate was 20%. A non-linear relationship was observed between platelet count and 28-day mortality. Two different slopes were identified, with correlations between platelet count and 28-day mortality in patients with IE differing significantly below and above the inflection point, which was approximately 141 K/µl. On the left side of the inflection point, the hazard ratio was 0.990 (hazard ratio: 0.990, 95% confidence interval: 0.982-0.997, p = 0.006). However, on the right side of the inflection point, the hazard ratio increased marginally to 1.0004 (HR: 1.0004, 95% CI: 0.997-1.004, p = 0.825). Notably, the association lacked statistical significance on the right side of the inflection point.

Conclusion

A nonlinear association between platelet count and 28-day mortality was observed in critically ill patients with infective endocarditis. The optimal platelet count associated with the lowest risk of 28-day mortality was above 141 k/µl.

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.

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.

Native mitral valve streptococcal endocarditis presenting as myocardial infarction and diagnosed with multimodality imaging

A man in his 60s presented to the emergency department with central crushing chest pain on a background of a week's history of flu-like symptoms. An ECG demonstrated ischaemia with blood tests confirming myocardial injury; catheter angiography revealed an obstructed diagonal coronary artery. In addition, blood tests revealed elevated markers of inflammation, blood cultures grew Streptococcus gordonii and transthoracic echocardiography demonstrated a mitral valve lesion. A diagnosis of embolic infarction secondary to native mitral valve infective endocarditis was made. Imaging with [18F]Flurodeoxyglucose Positron Emission Tomography CT, cardiac MRI and brain MRI confirmed myocardial infarction, mitral valve infection and embolic phenomena within the brain, respectively. This case reinforces the need for strategic flexibility when faced with evolving clinical data, the role of multidisciplinary involvement in an endocarditis team and the benefits of multimodality imaging techniques to secure diagnostic certainty.

Association between serum anion gap and 28-day mortality in critically ill patients with infective endocarditis: a retrospective cohort study from MIMIC IV database

BACKGROUND

The relationship between serum anion gap (AG) and 28-day mortality in critically ill patients with infective endocarditis is currently not well established.

OBJECTIVE

This study aims to investigate the impact of serum AG on 28-day mortality in critically ill patients with infective endocarditis.

METHODS

A retrospective cohort study was conducted involving 449 participants diagnosed with infective endocarditis and admitted to intensive care units (ICU). Vital signs, laboratory parameters and comorbidity were collected for all participants to analyze the association between anion gap levels and 28-day mortality.

RESULTS

A total of 449 critically ill patients with infective endocarditis (IE) were included in the study. The mean age was 57 years, and 64% were male. The overall 28-day mortality rate was 20%. A greater AG on admission were significantly associated with increased 28-day mortality in unadjusted analysis (hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.09-1.18; p < 0.001). After adjusting for all confounders, the association remained significant (adjusted HR 1.07; 95% CI 1.02-1.13; p = 0.003). When AG was converted into categorial variables (quartiles), the risk of 28-day mortality in the greatest Q4 group was significantly higher compared with that in the lowest Q1 group (model 4: HR = 2.62, 95%CI: 1.17-5.83, p = 0.019). Subgroup analysis showed consistent results across different groups.

CONCLUSION

A greater AG on admission were independently associated with increased 28-day mortality in critically ill patients with IE. These findings suggest that the AG can serve as a prognostic marker in this population, aiding in risk stratification and guiding clinical management.

Mitral valve repair and replacement in infectious endocarditis: a systematic review and meta-analysis of clinical outcome

BACKGROUND

Infective endocarditis (IE) poses significant clinical challenges, often necessitating surgical intervention for improved patient outcomes. The choice between mitral valve repair (MVP) and mitral valve replacement (MVR) is crucial in managing IE. This systematic review and meta-analysis aims to compare the effectiveness of MVP and MVR in treating IE, focusing on outcomes such as postoperative bleeding, mortality, recurrent endocarditis, and stroke.

MAIN TEXT

A comprehensive literature search was conducted following PRISMA guidelines. Studies directly comparing MVP and MVR in IE patients were included. Data extraction and quality assessment were performed, and meta-analysis was conducted using RevMan software. Thirty-two studies involving 82,123 patients were included. MVP was associated with significantly lower rates of postoperative bleeding (OR: 0.58, 95% CI: 0.40-0.84) and reduced long-term mortality (OR: 0.40, 95% CI: 0.32-0.51) compared to MVR. However, MVR showed lower rates of recurrent endocarditis. MVP was also associated with a decreased likelihood of postoperative stroke (OR: 0.52, 95% CI: 0.40-0.68).2, 4 CONCLUSIONS: MVP demonstrates advantages over MVR in reducing postoperative bleeding, long-term mortality, and stroke risk in IE patients. However, individual patient factors and surgical expertise must be considered in treatment decisions. Further research, including randomized controlled trials, is needed to validate these findings and refine treatment algorithms for IE management.

Echocardiography in Endocarditis

Infective endocarditis (IE) continues to have high rates of adverse outcomes, despite recent advances in diagnosis and management. Although the use of computer tomography and nuclear imaging appears to be increasing, echocardiography, widely available in most centers, is the recommended initial modality of choice to diagnose and consequently guide the management of IE in a timely-dependent fashion. Echocardiographic imaging should be performed as soon as the IE diagnosis is suspected. Several factors may delay diagnosis, for example, echocardiography findings may be negative early in the disease course. Thus, repeated echocardiography is recommended in patients with negative initial echocardiography if high suspicion for IE persists in patients at high risk. However, systematic echocardiographic screening should not be utilized as a common tool for fever, but only in the presence of a reasonable clinical suspicion of IE. It may increase the risk of false-positive rates of patients requiring IE therapy or may exacerbate diagnostic uncertainty about subtle findings. Considering the complexity of the disease, the echocardiographic use should be increasingly time-efficient and should focus on the correct identification of IE lesions and associated complications. The path to identify patients who need surgery passes through an echocardiographic skill ensuring the identification of the cardiac anatomical structures and their involvement in the destructive infective extension. We pointed out the role of echocardiography focused on the correct identification of IE distinctive lesions and the associated complications, as part of a diagnostic strategy, within an integrated multimodality imaging, managed by an "endocarditis team".

Granulomatosis With Polyangiitis Mimicking Infective Endocarditis: A Case Report

Granulomatosis with polyangiitis is a rare systemic disease that causes necrotizing granulomatous inflammation of small- and medium-sized blood vessels. We present the case of a 46-year-old male with medical history significant for chronic sinusitis, prior history of drug abuse, and a recent tooth infection. He was suspected to have infective endocarditis, but further workup revealed diagnostic findings of granulomatosis with polyangiitis. We discuss how the signs and symptoms of granulomatosis with polyangiitis can overlap with infective endocarditis, a pathophysiologically distinct condition with a strikingly similar presentation.

A surgical odyssey: Conquering a titanic tricuspid vegetation reaching into the superior vena cava - A case report

INTRODUCTION

Right-sided infective endocarditis, particularly of the tricuspid valve, is rare and challenging to diagnose, often presenting with nonspecific symptoms, and associated with high mortality rates. This case underscores the complexities in managing such conditions and the importance of early diagnosis and multidisciplinary intervention.

CASE PRESENTATION

This case study details the medical history of a 34-year-old woman who had a background of intravenous drug abuse. She subsequently developed a fungal tricuspid valve endocarditis, leading to the formation of vegetation that extended into the superior vena cava. The mass measured 15 × 3 cm upon surgical removal.

DISCUSSION

Right-sided infective endocarditis is rare, comprising only 5-10 % of cases, with tricuspid valve endocarditis being even rarer. Damage to the endothelium facilitates bacterial attachment, especially in IV drug users, with Staphylococcus aureus being common. Fungal endocarditis is rare but deadly, with high mortality. Diagnosis relies on the modified Duke criteria, including microbiological and imaging evidence. Major complications affect both valvular and systemic areas. Treatment p1rimarily involves IV antibiotics, but surgery is needed for persistent infections or severe complications.

CONCLUSION

This case underscores the critical importance of early diagnosis and intervention in managing right-sided infective endocarditis, especially with a fungal pathology and in patients with complex medical histories.

Effects of dexmedetomidine on renal function after cardiac surgery for infective endocarditis: An interim analysis of a randomized controlled trial

BACKGROUND

Patients undergoing cardiac surgery for infective endocarditis (IE) are at a high risk of postoperative acute kidney injury (AKI) owing to heightened systemic inflammation. Therefore, we aimed to investigate the effect of dexmedetomidine on postoperative AKI in patients who underwent cardiac surgery for IE.

METHODS

A total of 63 patients who underwent cardiac surgery for IE were randomly assigned to receive either intravenous dexmedetomidine infusion of 0.4 μg kg-1 h-1 (DEX group) or normal saline infusion (control group) for 24 h after induction of anesthesia. The occurrence of AKI within seven days postoperation, epinephrine, norepinephrine, and interleukin-6 levels, as well as postoperative morbidities, were assessed. An intertrim analysis was conducted using Pocock's alpha spending function at α = 0.05 and β = 0.2.

RESULTS

This trial was early terminated according to the results of interim analysis performed when 60 % of the pre-set number of patients have been collected. The incidence of AKI was significantly lower in the DEX group than in the control group (32.3 % vs. 9.4 %, p = 0.025). Patients in the DEX group had significantly lower epinephrine levels than those in the control group, whereas norepinephrine and interleukin-6 levels were similar. Perioperative mean arterial pressure or heart rate did not differ between the groups.

CONCLUSIONS

Dexmedetomidine administration for 24 h starting from induction of anesthesia significantly reduced the incidence of postoperative AKI after cardiac surgery for IE (by 29 % vs. control) without hemodynamic side effects. This was accompanied by a significant attenuation of postoperative increase in serum epinephrine levels.

Increase in Oral Streptococcal Endocarditis Among Moderate-Risk Patients: Impact of Guideline Changes on Endocarditis Prevention

Background

The well-established connection between oral bacteria and infective endocarditis (IE) has prompted discussions about using antibiotic prophylaxis (AP) before invasive dental procedures. In 2007/2008, guidelines restricted AP from moderate and high-risk to exclusively high-risk patients.

Objectives

The authors aimed to assess whether the proportion of oral streptococcal IE increased in moderate-risk patients using University Hospital Zurich data from 2000 to 2022.

Methods

Adult IE patients were categorized into risk groups based on European Society of Cardiology and Swiss guidelines. The investigation focused on analyzing the proportion of oral streptococcal IE across different risk groups in two distinct periods (1: 2000-2008; 2: 2009-2022). Logistic regression models, adjusted for various factors, were employed.

Results

Of 752 IE cases, 163 occurred in period 1, and 589 in period 2. Oral streptococci caused 22% of cases. Proportions of streptococcal IE in period 1 versus period 2 were 24% versus 16% in high-risk, 24% versus 39% in moderate-risk, 33% versus 7% in low-/unknown-risk, and 18% versus 14% in no-risk patients. Compared to the other risk groups, the moderate-risk group had a 22% higher chance of oral streptococcal IE in period 2. After multivariable adjustment, moderate-risk patients had twice the risk of oral streptococcal IE compared to period 1 (OR: 2.59 [95% CI: 1.16-5.81]). Among moderate-risk conditions, congenital valve anomalies were associated with oral streptococcal IE (unadjusted OR: 2.52 [95% CI: 1.71-3.71]).

Conclusions

Oral streptococcal IEs increased in the moderate-risk group of patients after the AP guideline change. Exploring the potential necessity for expanding AP indications to certain patient groups with congenital valve anomalies may be warranted.

Preoperative fibrinogen level predicts the risk and prognosis of patients with native valve infective endocarditis undergoing valve surgery

Aim

The aim of this study was to assess the clinical significance and prognostic value of the preoperative fibrinogen (FBG) level in patients with native valve infective endocarditis (NVIE) who underwent valve surgery.

Methods

This retrospective study included a total of 163 consecutive patients who were diagnosed with NVIE and underwent valve surgery from January 2019 to January 2022 in our hospital. The primary endpoint was all-cause mortality.

Results

All-cause mortality was observed in 9.2% of the patients (n = 15). Body mass index (BMI) was lower in the survival group (p = 0.025), whereas FBG (p = 0.008) and platelet count (p = 0.044) were significantly greater in the survival group than in the death group. Multivariate Cox proportional hazards analysis revealed that FBG (HR, 0.55; 95% CI, [0.32-0.94]; p = 0.029) was an independent prognostic factor for all-cause mortality. Furthermore, Kaplan‒Meier survival curve analysis revealed that patients with low FBG levels (<3.28 g/L) had a significantly greater mortality rate (p = 0.034) than did those with high FBG levels (>3.99 g/L). In the trend analysis, the FBG tertiles were significantly related to all-cause mortality in all three adjusted models, and the p values for trend were 0.017, 0.016, and 0.028, respectively.

Conclusion

Preoperative FBG may serve as a prognostic factor for all-cause mortality, and an FBG concentration less than 3.28 g/L was associated with a greater risk of all-cause mortality in NVIE patients undergoing valve surgery.