Infective endocarditis in solid organ transplant recipients

A Repertoire of Clinical Non-Dermatophytes Moulds

Humans are constantly exposed to micromycetes, especially filamentous fungi that are ubiquitous in the environment. In the presence of risk factors, mostly related to an alteration of immunity, the non-dermatophyte fungi can then become opportunistic pathogens, causing superficial, deep or disseminated infections. With new molecular tools applied to medical mycology and revisions in taxonomy, the number of fungi described in humans is rising. Some rare species are emerging, and others more frequent are increasing. The aim of this review is to (i) inventory the filamentous fungi found in humans and (ii) provide details on the anatomical sites where they have been identified and the semiology of infections. Among the 239,890 fungi taxa and corresponding synonyms, if any, retrieved from the Mycobank and NCBI Taxonomy databases, we were able to identify 565 moulds in humans. These filamentous fungi were identified in one or more anatomical sites. From a clinical point of view, this review allows us to realize that some uncommon fungi isolated in non-sterile sites may be involved in invasive infections. It may present a first step in the understanding of the pathogenicity of filamentous fungi and the interpretation of the results obtained with the new molecular diagnostic tools.

Infective endocarditis in solid organ transplant: a review

PURPOSE OF REVIEW

Infective endocarditis remains an uncommon disease with significant morbidity and mortality. In the last two decades, progress has been made describing the unique aspects of infective endocarditis in solid organ transplant (SOT) recipients.

RECENT FINDINGS

Incidence of infective endocarditis in SOT is higher when compared with the general population. End-stage organ dysfunction, diabetes mellitus, older age, and prior intravenous lines have been identified as risk factors predisposing to infective endocarditis in SOT. Staphylococci and enterococci represent the most frequently isolated pathogens, whereas fungi are rarely isolated. Median time from transplantation to diagnosis ranges from 33 to 66 months. Nosocomial acquisition and mural endocarditis are more common in SOT recipients with infective endocarditis. Procurement of organs from patients with infective endocarditis might be well tolerated so long as close monitoring and targeted antibiotics are given. Selected patients might benefit from heart transplantation as definitive or salvage therapy for infective endocarditis. Outcomes of infective endocarditis in SOT recipients compared with the general population might be similar; however, patient survival and graft function are reduced when recipients suffer from infective endocarditis.

SUMMARY

Infective endocarditis although rare can affect donors and recipients involved in the SOT process. Recognition of the unique characteristics in the presentation, prevention, medical, and surgical therapy of this disease is essential in order to minimize adverse outcomes.

Permanent pacing in a very long-term follow-up after orthotopic heart transplantation: A matter of when or why?

Background

Orthotopic heart transplantation (OHT) is associated with a high incidence of conduction disturbances (CD) leading to permanent pacemaker (PPM) implantation. However, the improved posttransplant survival raises the question about the pacemaker dependence (PD) in a prolonged follow‐up.

Hypothesis

The prevalence of PPM in OHT is high but not all patients are PD in a very long‐term follow‐up. Device implantation has no prognostic relevance.

Methods

We performed a retrospective analysis of patient medical records focusing on device interrogation data at the most recent follow‐up.

Results

The study population consisted of 183 patients with a mean follow‐up of 15.0 ± 6.8 years. One‐fourth of the patients had undergone PPM implantation (n = 49, 26.8%). Among these, two‐thirds were PD at last follow‐up (n = 32, 65.3%). PPM was more often in biatrial OHT and cardiac allograft vasculopathy (OR 3.0, 95% CI 1.26–7.29, p = .013 and OR 2.0, 95% CI 1.03–3.87, p = .041, respectively). Early sinus node dysfunction (SND) was the most persistent CD. PPM was associated with a poorer outcome in OHT (HR 1.9, 95% CI 1.06–3.46, p = .031) and a higher rate of fatal septicemia (HR 5.1, 95% CI 1.41–18.14, p = .013).

Conclusions

One‐fourth of the OHT recipients develop CD requiring PPM implantation, although one‐third among these are not PD in follow‐up. Early SND is associated with a higher rate of PD. PPM is associated with an inferior prognosis.

In-hospital mortality and length of stay among patients with infective endocarditis and solid organ transplant: A study from National Inpatient Sample 2016-2019

Infective endocarditis (IE) is a rare but serious complication following a Solid Organ Transplant (SOT). Due to the lack of sufficient studies, we aimed to compare in-hospital mortality and length of stay (LOS) of patients primarily admitted for IE (index or principal hospitalization) with history of SOT, including the subgroup of heart or lung transplant (HLT), to those without a history of SOT (non-SOT) or HLT (non-HLT). We used the 2016–2019 National Inpatient Sample, the largest all-payer inpatient hospital data from Healthcare Cost and Utilization Project (HCUP), including patients 18 years or older with IE, as a principal diagnosis for hospitalization. From 2016 to 2019, there were 56,330 principal or index hospitalizations for IE. Among them, 0.6 % (n = 327) were SOT recipients, 0.1% (n = 68) were HLT recipients, and 41.4% were females. The mean age was 51.9 ± 19.2 years. Compared to non-SOT controls, SOT recipients were older (mean age 59.3 vs. 51.8 years; P = 0.002) and had higher Charlson-comorbidity-index (CCI) of 3 or more (87.7% vs. 33.2%; p < 0.001). SOT status was not statistically significant for a higher or lower odds of in-hospital mortality (adjusted odds ratio (aOR) 0.7; 95% confidence interval (CI): 0.2, 2.4; p = 0.60) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.4, 0.1; p = 0.23) among index IE hospitalizations after controlling for age, sex, race, hospital-region, hospital-teaching status, income, insurance status, and CCI. HLT status was also not associated with higher or lower odds of in-hospital mortality (aOR 1.4; 95% CI: 0.2, 13.1; p = 0.77) or increased or decreased LOS (coefficient: -0.1, 95% CI: -0.3, 0.5; p = 0.59). From 2016 to 2019, the rate of index IE hospitalization trends from 37.8 to 41.4 per 100,000 overall hospitalizations (p = 0.001). We found the rate of index IE hospitalizations increasing with time. Among index IE hospitalizations, SOT, including a subgroup of HLT recipients, have similar in-hospital mortality and LOS compared to non-SOT or non-HLT groups. We need a larger sample size to comment on outcomes of IE hospitalizations with the HLT subgroup.

Infective endocarditis and solid organ transplantation: Only worse outcomes during initial transplantation hospitalization

BACKGROUND

The epidemiology, and outcome of infective endocarditis (IE) among solid organ transplant (SOT) recipients is unknown.

METHODS

We used data from the 2013-2018 Nationwide Readmissions Database (NRD). IE- and SOT-associated hospitalizations were identified using diagnosis and procedure codes. Outcomes included inpatient mortality, length of stay, and inpatient costs. Adjusted analyses were performed using weighted regression models.

RESULTS

A total of 99,052 IE-associated hospitalizations, corresponding to a weighted national estimate of 193,164, were included for analysis. Of these, 794 (weighted n = 1,574) were associated with transplant history (SOT-IE). Mortality was not significantly different between SOT-IE and non-SOT-IE (17.2% vs. 15.8%, adjusted relative risk [aRR]: 0.86, 95% confidence interval [CI] [0.71, 1.03]), and fewer SOT-IE patients underwent valve repair or replacement than non-SOT-IE (12.5% vs. 16.2%, aRR 0.82, 95% CI [0.71, 0.95]). We then compared outcomes of patients diagnosed with IE during their index transplant hospitalization (index-SOT-IE) to patients without IE during their transplant hospitalization (index-SOT). Index-SOT-IE occurred most frequently among heart transplant recipients (45.1%), and was associated with greater mortality (27.1% vs. 2.3%, aRR 6.07, 95% CI [3.32, 11.11]).

CONCLUSION

Dual diagnosis of SOT and IE was associated with worse outcomes among SOT recipients during index hospitalization, but not overall among patients with IE.

High Mortality and Graft Loss after Infective Endocarditis in Kidney Transplant Recipients: A Case-Controlled Study from Two Centers

Kidney transplant recipients (KTRs) tend to develop infections with characteristic epidemiology, presentation, and outcome. While infective endocarditis (IE) is among such complications in KTRs, the literature is scarce. We describe the presentation, epidemiology, and factors associated with IE in KTRs. We performed a retrospective case/control study which included patients from two centers. First episodes of definite or possible IE (Duke criteria) in adult KTRs from January 2010 to December 2018 were included, as well as two controls per case, and followed until 31 December 2019. Clinical, biological, and microbiological data and the outcome were collected. Survival was studied using the Kaplan-Meier method. Finally, we searched for factors associated with the onset of IE in KTRs by the comparison of cases and controls. Seventeen cases and 34 controls were included. IE was diagnosed after a mean delay of 78 months after KT, mostly on native valves of the left heart only. Pathogens of digestive origin were most frequently involved (six Enterococcus spp, three Streptococcus gallolyticus, and one Escherichia coli), followed by Staphylococci (three cases of S. aureus and S. epidermidis each). Among the risk factors evaluated, age, vascular nephropathy, and elevated calcineurin inhibitor through levels were significantly associated with the occurrence of IE in our study. Patient and death-censored graft survival were greatly diminished five years after IE, compared to controls being 50.3% vs. 80.6% (p < 0.003) and 29.7% vs. 87.5% (p < 0.002), respectively. IE in KTRs is a disease that carries significant risks both for the survival of the patient and the transplant.

Endocarditis in Liver Transplant Recipients: A Systematic Review

Infective Endocarditis (IE) is associated with significant mortality. Interestingly, IE in patients with liver transplantation has not been adequately described. The aim of this review was to systematically review all published cases of IE in liver transplant recipients and describe their epidemiology, microbiology, clinical characteristics, treatment and outcomes. A systematic review of PubMed, Scopus and Cochrane Library (through 2 January 2021) for studies providing epidemiological, clinical, microbiological, treatment data and outcomes of IE in liver transplant recipients was conducted. A total of 39 studies, containing data for 62 patients, were included in the analysis. The most common causative pathogens were gram-positive microorganisms in 69.4%, fungi in 25.8%, and gram-negative microorganisms in 9.7% of cases, while in 9.3% IE was culture-negative. The aortic valve was the most commonly infected valve followed by mitral, tricuspid and the pulmonary valve. Aminoglycosides, vancomycin and aminopenicillins were the most commonly used antimicrobials, and surgical management was performed in half of the cases. Clinical cure was noted in 57.4%, while overall mortality was 43.5%. To conclude, this systematic review thoroughly describes IE in liver transplant recipients and provides information on epidemiology, clinical presentation, treatment and outcomes.

Infective endocarditis in patients with solid organ transplantation. A nationwide descriptive study

BACKGROUND

Solid organ transplantation (SOT) implies immunosuppression and frequent health care contact. Our aim was to compare the characteristics of patients with infective endocarditis (IE) and SOT against those without SOT.

METHODS

We used data from the Spanish Collaboration on Endocarditis during the period 2008-2018.

RESULTS

We identified 4794 cases of IE, 85 (1.8%) in SOT (56 kidney, 18 liver, 8 heart, 3 lung). Thirteen patients with other transplantation types (bone marrow, hematopoietic precursors, and cornea) were excluded from the analysis. Compared with patients without SOT, patients with SOT had lower median age (61 vs. 69 years, p<0.001), more comorbidities (mean age-adjusted Charlson index 5.7±2.9 vs. 4.9±2.9, p=0.004), a lower prevalence of native valvular heart disease (29.4 vs. 45.4%, p=0.003), more in-hospital and healthcare-related IE (70.5% vs. 36.3%, p<0.001) and staphylococcal etiology (57.7% vs. 39.7%, p=0.001). Patients with SOT had more frequent kidney function worsening (47.1% vs. 34.6%, p=0.02), septic shock (25.9% vs. 12.1 %, p<0.001), sepsis (27.1% vs. 17.2%, p=0.02), and less surgery indication (54.1% vs 66.3%, p=0.02) and surgery (32.9% vs. 46.3%, p=0.01) than patients without SOT. There were no significant differences in mortality: inhospital (30.6% SOT vs. 25.6% without SOT, p=0.31), 1-year (38.8% SOT vs. 31.9% without SOT, p=0.18).

CONCLUSIONS

Most IE in SOT recipients are nosocomial and over 70% are health care-related. Half have previously normal heart valves and almost 60% are due to Staphylococcus spp. infections. Mortality seems to be similar to non-SOT counterparts.

Endocarditis in kidney transplant recipients: a systematic review

Infective Endocarditis (IE) carries significant mortality. Bacteremia, which is a predisposing factor for IE, occurs more frequently in immunocompromised individuals. Interestingly, IE in kidney transplant recipients has not been adequately described. The aim of this study was to systematically review all published cases of IE in kidney transplant recipients and describe their epidemiology, microbiology, clinical characteristics, treatment and outcomes. A systematic review of PubMed (through 13^th December 2019) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE in kidney transplant recipients was performed. A total of 60 studies, containing data of 117 patients, were included in the analysis. The most common causative pathogens were gram-positive microorganisms in 57.4%, gram-negative microorganisms in 14.8%, fungi in 20%, while in 18.9% of cases, IE was culture-negative. Aortic valve was the most commonly infected valve followed by mitral, tricuspid and the pulmonary valve. Diagnosis was set with a transthoracic ultrasound in half the cases, followed by transesophageal ultrasound and autopsy. Fever was present in most cases, while embolic phenomena were noted in two out of five cases. Aminoglycosides, cephalosporins and aminopenicillins were the most commonly used antimicrobials, and surgical management was performed in one out of three cases. Clinical cure was noted in 60.9%, while overall mortality was 45.3%. To conclude, this systematic review thoroughly describes IE in kidney transplant recipients and provides information on epidemiology, clinical presentation, treatment and outcomes. Moreover, it identifies the emerging role of Enterococci, gram-negatives and fungi in IE in this population.

Fungal endocarditis in transplant recipients: A systematic review

BACKGROUND

Invasive fungal infections remain a major cause of morbidity and mortality in transplant recipients. Moreover, Fungal Infective Endocarditis (FIE) is a rare infection that carries a higher mortality than bacterial IE in normal host, while in transplant recipients may be even higher. The purpose of this study was to systemically review all published cases of FIE in solid organ and allogeneic bone marrow transplant recipients, describe the epidemiology, microbiology, clinical characteristics, treatment and outcomes of these infections, and to identify risk factors for mortality by FIE.

METHODS

A systematic review of PubMed, Scopus and Cochrane Library (through 20 May 2020) for studies providing epidemiological, clinical, microbiological and treatment data and outcomes of FIE in transplant recipients was performed.

RESULTS

A total of 60 studies, containing data of 72 patients, were included. The most common transplants were those of the kidney and the liver, while the commonest causative pathogen was Aspergillus. Mitral valve was the commonest infected intracardiac site, followed by mural endocardium. Diagnosis was made with transthoracic echocardiography in 44.3%, while the diagnosis was made at autopsy in 37.3%. Embolic phenomena were the commonest clinical presentation, followed by fever, heart failure and endophthalmitis. Amphotericin B, voriconazole and caspofungin were the commonest antifungals used for treatment of FIE. Clinical cure was noted in 26.9%, while overall mortality was 78.6%. Amphotericin B or caspofungin use was negatively associated with overall mortality.

CONCLUSIONS

This systematic review thoroughly describes IE in transplant recipients and provides information on epidemiology, clinical presentation, treatment and outcomes.

Matched retrospective study of infective endocarditis among solid organ transplant recipients compared to non-transplant: Seven-year experience in a US Referral Center

BACKGROUND

Infective endocarditis (IE) is a rare complication following solid organ transplant (SOT); data on the clinical features and outcomes of IE in SOT recipients in the modern era are limited.

METHODS

We conducted a single-center retrospective cohort study of IE diagnosed from 1/2008-12/2014 in SOT recipients, who were matched by age and microorganism to cases of IE in non-SOT, to describe the clinical features and outcomes.

RESULTS

There were 14 cases of IE identified in SOT recipients matched to 56 non-SOT controls. Median time from transplant to IE was 1017 days (IQR 379-1830). Compared to non-SOT patients, SOT patients were more likely to be undergoing current hemodialysis (16% vs 36%) and to possess indwelling central venous catheters within the 30 days prior to diagnosis of IE (27% vs 50%). No SOT patients had documented drug use as a risk factor for IE whereas 6 (11%) non-SOT did. Enterococcus was the most common etiologic agent and was isolated in 50% of cases; only one fungal infection was identified, a mixed infection with Candida. Thirty-day mortality was 14% in SOT patients, significantly higher versus no deaths in non-SOT (P = .037).

CONCLUSIONS

The present study illustrates a change in epidemiology of IE in SOT patients characterized by IE that generally occurs more than one-year post-transplant, is due to bacterial infection rather than fungus, and appears to be health care associated. Multicenter studies are merited to explore transplant-specific risk factors for IE in the special population of SOT patients.

Management of Antimicrobial Agents in Abdominal Organ Transplant Patients in Intensive Care Unit

PURPOSE OF REVIEW

Early diagnosis of infections and immediate initiation of appropriate antimicrobials are crucial in the management of patients before and after organ transplantation. We reviewed the most recent literature and guidelines in this field and organized the current recommendations for healthcare professionals caring for critically ill organ transplant recipients.

RECENT FINDINGS

The incidence of multidrug-resistant organisms is increasing. Multidrug-resistant Gram-negative bacteria comprise about 14% of organisms. Vancomycin-resistant enterococci bloodstream infections are also on the rise, as 20.5% of nosocomial enterococci are now vancomycin-resistant, changing empiric antibiotic selection. Fluconazole-resistant Candida species comprise up to 46% of cases of candidemia in hospitalized patients. Consequently, new guidelines recommend primary use of echinocandins in patients with candidemia who have moderate-to-severe disease. Finally, the incidence of emergence of ganciclovir-resistant cytomegalovirus infection in patients is 5-12%, requiring early recognition and change to alternative regimens in the case of poor response to therapy.

SUMMARY

Bloodstream infections are a major cause of mortality and morbidity in solid organ transplantation. Mortality as high as 24% and 50% have been reported with sepsis and septic shock respectively. As such, bloodstream infections should be diagnosed rapidly and intravenous antibiotics should be started immediately. Appropriate resuscitation should be initiated and the number and/or dose of immunosuppressive drugs should be reduced. Proper source control must also be achieved with radiologic drainage or surgical intervention as appropriate. Initial antibiotic treatment of these patients should cover both Gram-positive organisms, especially in the presence of intravascular catheters, and Gram-negative bacteria. Echinocandins like caspofungin should also be considered especially in critically ill patients, particularly if a patient has been on total parenteral nutrition or broad-spectrum antibiotics.

A Case of Aspergillus Mural Endocarditis Presenting With Complete Atrioventricular Block after Liver-Kidney Transplantation

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Aspergillus endocarditis is a rare but fatal complication in immunocompromised hosts.

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Aspergillus mural endocarditis is rapidly progressive and shows a fatal outcome.

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Clinical suspicion and early echocardiography are key for the diagnosis.

Adequacy of infective endocarditis prophylaxis before dental procedures among solid organ transplant recipients

Infective endocarditis (IE) is a life-threatening condition with high morbidity and mortality. The current IE guidelines recommend antibiotic prophylaxis only in patients with certain cardiac conditions and before certain dental procedures. However, there is not enough data about solid organ transplant (SOT) recipients. In this study, we aimed to investigate the IE prophylaxis in general dental and periodontal surgical procedures among our SOT recipients. Medical records of 191 SOT recipients (32 liver transplant recipients, 54 heart transplant recipients, and 105 kidney transplant recipients) who were admitted to our hospital between January 2016 and January 2018 were evaluated. A total of 65 patients who underwent dental procedures were included in the study. We investigated the adequacy of IE prophylaxis according to the current guidelines. Two groups were created according to whether they received antibiotic prophylaxis or not. The mean age was 44.2 ± 13.6 years, and 66.1% were male. The majority of patients (67.6%) received antibiotic prophylaxis. The most commonly used antibiotic was amoxicillin (48.8%). Among the procedures, 23.1% were classified as invasive and 76.9% were classified as noninvasive. No complication was observed after invasive and noninvasive dental procedures. There were no complications in both antibiotic prophylaxis and no-prophylaxis groups. According to our results, IE prophylaxis has been used appropriately in SOT recipients in our center. No serious infection has been reported. In addition, no complication due to antibiotic use was also observed.

A rationale for combination ampicillin and daptomycin in renal transplant patients with enterococcal infective endocarditis

Treatment of enterococcal endocarditis in patients with history of renal transplantation is complicated. Treatment failure and/or drug toxicities are not uncommon. Treatment with ampicillin and daptomycin in a renal transplant patient has been rarely reported. Here we report a patient who was successfully treated with this novel combination.

Aspergillus flavus native valve endocarditis following combined liver and renal transplantation: Case report and review of the literature

Aspergillus endocarditis is a rare infection that occurs most commonly in patients with prior cardiac surgery but cases in post-transplant recipients without prior cardiac surgery have been reported. Diagnosis is often delayed and requires high index of suspicion. We here report a case of Aspergillus endocarditis in solid organ transplant recipient.

Infective endocarditis after renal transplantation

Background:

Infective endocarditis (IE) is a serious complication in immunosuppressive patients that has adverse effects.

Objectives:

The aim of this study was to define the characteristics, outcomes, and correlating factors of mortality in renal transplant recipients.

Patients and Methods:

Infective endocarditis was diagnosed in 22 patients from three renal transplant centers in Iran between 2000 and 2010. Modified Duke criteria were applied to confirm the diagnosis.

Results:

Twenty-two renal transplant patients with IE were evaluated. Blood culture results were positive in 81%. Enteroccous and group D non-enterococcal were the causative microorganisms in 31% and 25% of patients, respectively. In-hospital and 12-month mortality was 41% and the mortality rate was higher in older patients in comparison to younger patients. Overall, the rates of one-year disease-free patient and graft survival were 49% and 88%, respectively.

Conclusions:

Despite the availability of different and potent antibiotics, the mortality caused by IE remains considerably high. These patients are significantly prone to endovascular infections that affect the mortality and survival.

Gram-negative bacteria causing infective endocarditis: Rare cardiac complication after liver transplantation

Bacterial endocarditis is a rare complication amongst solid organ transplant recipients and is often linked to bacteremia. Majority of these recipients do not have underlying valvular heart disease or congenital valvular abnormalities. Staphylococoocusaureus and Enterococcus species are the most commonly isolated organisms. There are very few reports of gram-negative bacteria causing endocarditis in liver transplant recipients. We report a 51-year-old male, a liver transplant recipient, who developed bacterial endocarditis of the mitral valve due to extended spectrum of betalactamase producing strain of Escherichia coli and was managed successfully with antibiotics.

Orofacial diseases in solid organ and hematopoietic stem cell transplant recipients

OBJECTIVE

Solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients are at risk of several diseases, principally attributable to immunosuppression. This global overview of SOT/HSCT-associated orofacial diseases is aimed at providing a practical instrument for the oral healthcare management of SOT/HSCT recipients.

METHODS

Literature search was made through MEDLINE. The associations between orofacial diseases and SOT/HSCT were assessed using observational studies and case series and were classified into 'association', 'no association', and 'unclear association'.

RESULTS

Lip/oral cancers, drug-induced gingival overgrowth (DIGO), infections, including hairy leukoplakia and, less frequently, post-transplantation lymphoproliferative disorders (PTLDs) and oral lichenoid lesions of graft-versus-host disease (GVHD), were associated with SOT. Lip/oral cancers, GVHD, mucositis, DIGO, infections and, less frequently, PTLDs were associated with HSCT. Associations of orofacial granulomatosis-like lesions and oral mucosa-associated lymphoid tissue-type lymphoma with SOT, and of pyogenic granuloma and hairy leukoplakia with HSCT were unclear. Periodontal disease and dental caries were not associated with SOT/HSCT. For none of the local treatments was there a strong evidence of effectiveness.

CONCLUSIONS

Solid organ transplant/HSCT recipients are at risk of orofacial diseases. Adequate management of these patients alleviates local symptoms responsible for impaired eating, helps prevent systemic and lethal complications, and helps where dental healthcare has been neglected.

Single center experience of a vancomycin resistant enterococcal endocarditis cohort

OBJECTIVES

Vancomycin resistant enterococcus (VRE) infective endocarditis (IE) is an increasing nosocomial problem. We describe the clinical management and outcomes of a cohort of patients with VRE IE at a tertiary endocarditis referral center.

METHODS

Retrospective review of all proven cases of VRE IE, from July 2000 through January 2008 was performed. Demographics, comorbidities and therapeutic details were collected and analyzed to assess for risk factors and clinical outcomes.

RESULTS

Fifty cases of VRE IE were identified: 26 (52%) were Enterococcus faecium and 24 were Enterococcus faecalis. Vancomycin resistant E. faecalis IE was associated with the presence of a central venous line, liver transplantation, and mitral valve infection while VR E. faecium IE was significantly associated with tricuspid valve infection (p=0.03). The median duration of bacteremia was 14 days for E. faecium and 4 days for E. faecalis, respectively (p=0.002). Factors associated with mortality on bivariate analysis were hemodialysis via a catheter with VR E. faecium (OR=11.7. CI 1.1-122, p=0.02) and liver transplantation with both species. Combination antimicrobial therapy (OR=0.5 CI=0.06-3.2, p=0.1) and valve surgery (OR 1.3 CI 0.8-20, p=0.02) trended toward improved survival with E. faecalis on bivariate analysis. On multivariate analysis, none of the associations were significant.

CONCLUSIONS

Hemodialysis and liver transplantation were factors associated with acquisition of VRE IE. There was a higher mortality and prolonged bacteremia with VR E. faecium IE than VR E. faecalis IE. Although not significant, combination antimicrobial therapy and surgical intervention trended toward improved survival.

Candida albicans tricuspid and pulmonic valve endocarditis: Challenge of relapsing risk and role of combined medical treatment and surgery

Candida albicans endocarditis involves infrequently the tricuspid valve and involvement of the pulmonic valve is rare. We report our experience with an immunosuppressed liver-transplanted female who developed both tricuspid and pulmonic valve endocarditis, review the literature and discuss the importance of effective antimycotic therapy combined with surgical replacement of the affected valve.

Successful treatment of Staphylococcus aureus bacterial endocarditis in a renal transplant recipient

We report the successful treatment of Staphylococcus aureus endocarditis in a renal transplant recipient with preservation of his renal allograft. A 44-year-old man presented to the emergency room with sudden onset of fevers and rigors 7 weeks after renal transplantation. Infective endocarditis was diagnosed by Duke's Criteria (Durack et al. New criteria for the diagnosis of infective endocarditis. Am J Med 1994: 96: 200-209) with multiple positive blood cultures for S. aureus and a mitral valve vegetation on transesophageal echocardiogram. He was treated with intravenous antibiotics for 6 weeks with continuation of his immunosuppression. He has remained clinically stable for over 5 years. Although the treatment of S. aureus endocarditis in immunosuppressed transplant patients has traditionally resulted in loss of their allograft, prompt diagnosis and appropriate antibiotics with continued immunosuppressive therapy resulted in a successful outcome and allograft preservation in this case.

Outcomes of renal transplant and waiting list patients with bacterial endocarditis in the United States

BACKGROUND

Bacterial endocarditis is associated with poor long-term survival among dialysis patients. Renal transplant patients and those waiting list for renal transplantation are predisposed to developing bacterial endocarditis; data regarding incidence and outcomes are limited.

METHODS

Patients hospitalised for bacterial endocarditis were identified from patients transplanted or waiting list between 1995 and 2003. Transplant and waiting list cohorts were derived from the United States Renal Data System (USRDS) database. All patients had Medicare as primary payer. Long-term survival was estimated by the Kaplan-Meier method. Cox proportional hazards analysis was used to identify independent predictors of bacterial endocarditis.

RESULTS

During the study period, 282 renal transplant patients and 549 waiting list patients were hospitalised with bacterial endocarditis. Incidence rates of bacterial endocarditis per 1000 patient-years were 5.6 among waiting list patients, 2.6 among deceased-donor transplant recipients and 1.8 among living-donor transplant recipients. In-hospital mortality rates were 16.0% for the renal transplant cohort and 18.6% for the waiting list cohort. Two-year post-endocarditis survival rates were 58% for transplant patients and 41% for waiting list patients. The most powerful predictors of bacterial endocarditis among transplant patients were donor age, patient age, diabetic end-stage renal disease (ESRD) and prior dialysis time longer than 2 years.

CONCLUSIONS

Renal transplant patients hospitalised with bacterial endocarditis sustain high in-hospital and long-term mortality rates. Waiting list patients are at higher risk of developing bacterial endocarditis than renal transplant recipients.

Post-operative aspergillosis

While invasive aspergillosis occurs typically in severely immunocompromised patients, cases of surgical site infection have been reported in immunocompetent individuals. The Medline, LILACS and EMBASE databases were searched for descriptions of cases of post-operative aspergillosis, and references from relevant articles and conference abstracts were reviewed. More than 500 cases of post-operative aspergillosis were found. Cardiac surgery (n = 188), ophthalmological surgery (n > 90) and dental surgery (n > 100) were associated with the majority of cases. Other cases involved wound infections (n = 22), bronchial infections (n = 30), mediastinitis (n = 11), pleural aspergillosis (n = 1), infections following orthopaedic surgery (n = 42), vascular prosthetic surgery (n = 22), breast surgery (n = 5), abdominal surgery (n = 10) and neurosurgery (n = 25). In most patients, the source was presumed to be airborne infection during the surgical procedure. Prevention of these infections requires special care of the ventilation system in the operating room. Successful treatment requires rapid diagnosis, surgical debridement and antifungal therapy, often with voriconazole. In order to improve the outcome, better diagnostic methods are needed, particularly for cases of endocarditis and aortitis.

Endocarditis Due to Vancomycin-Resistant Enterococci: Case Report and Review of the Literature

BACKGROUND

Endocarditis due to vancomycin-resistant enterococci (VRE) is rare, and the literature consists almost exclusively of reports of single cases.

METHODS

We report a case of VRE prosthetic valve endocarditis and review 18 cases of native and prosthetic valve VRE endocarditis reported in the literature.

RESULTS

The majority of cases were due to Enterococcus faecium. Nearly all of these infections were hospital acquired, and the vast majority of patients had significant underlying disease processes, including dialysis and transplantation. More than three-quarters of cases were left-sided, and the aortic valve was most commonly involved. Peripheral stigmata of endocarditis were not reported in any of the cases. Approximately 40% of patients developed cardiac complications. Nearly three-quarters of patients survived, despite the difficulties associated with providing bactericidal antimicrobial therapy, and only 4 patients underwent valve replacement.

CONCLUSIONS

VRE endocarditis is an uncommon nosocomial infection that affects patients with significant comorbid conditions. Most cases are due to E. faecium, and the aortic valve is involved in at least one-half of cases. One-third of patients require surgical treatment. Optimal antimicrobial therapy remains undefined, but an attempt to identify bactericidal combination therapy should be sought.

The invasive and saprophytic syndromes due to Aspergillus spp

Aspergillus spp. produce a wide range of invasive and sapropytic syndromes which may involve any tissue. Within a given tissue or organ the pathology and pathogenesis varies enormously, ranging from angioinvasive disease to noninvasive saprophytic disease. The individual invasive and saprophytic syndromes in which a causative role can be attributed to Aspergillus spp. are detailed specifically with reference to the underlying pathology and pathogenesis, the clinical setting and features, and the manner in which a diagnosis can be established.

Severe endocarditis in transplant recipients--an epidemiologic study

Infective endocarditis (IE) is reported with an incidence of 6/100,000 inhabitants in the general population. Even though immunosuppression predisposes to systemic infection, reports regarding IE after solid organ transplantation (SOT) are sparse. From 1989 to 2004, 2556 patients underwent SOT at the University Hospital Innsbruck. During this period, 27 transplant recipients were diagnosed IE. Nine patients (33.3%) were diagnosed at autopsy, eight patients (29.6%) were cured by antibiotic treatment and 10 patients (37.1%) underwent surgery. Overall mortality was 44.4% (12 patients). Staphylococcus was the predominant microorganism in 16 cases (59.3%), fungal infection was present in four patients (14.8%). Incidence of IE was 1% (95% CI: 0.67-1.49), indicating a 171-fold risk compared with the overall population. IE after SOT constitutes a significant problem and is associated with an excessive high mortality. Alertness to this condition is indicated, as we might diagnose more cases of IE in the future.

Aspergillus infections in transplant recipients

Aspergillus infections are occurring with an increasing frequency in transplant recipients. Notable changes in the epidemiologic characteristics of this infection have occurred; these include a change in risk factors and later onset of infection. Management of invasive aspergillosis continues to be challenging, and the mortality rate, despite the use of newer antifungal agents, remains unacceptably high. Performing molecular studies to discern new targets for antifungal activity, identifying signaling pathways that may be amenable to immunologic interventions, assessing combination regimens of antifungal agents or combining antifungal agents with modulation of the host defense mechanisms, and devising diagnostic assays that can rapidly and reliably diagnose infections represent areas for future investigations that may lead to further improvement in outcomes.

Infective endocarditis following orthotopic heart transplantation: 10 cases and a review of the literature

BACKGROUND

Infective endocarditis is a known complication of cardiac transplantation. However, published information has been limited to case reports and small case series.

METHODS

Cardiac transplantation has been performed at Temple University Hospital since 1983. We identified transplant patients with ICD-9 codes for endocarditis or bacteremia. A diagnosis of endocarditis required fulfillment of the Duke criteria and presence of a vegetation. Clinical and microbiologic data were collected. Demographic and survival information were compared with heart transplant recipients without endocarditis. We reviewed all previously published cases using a MEDLINE search.

RESULTS

Ten of 659 heart transplant recipients had endocarditis (1.5%, 187 cases per 100,000 person years). Mitral and tricuspid valves were involved predominantly. No patient had aortic valve infection. Patients with tricuspid valve infection had a greater median number of endomyocardial biopsies (n=23) than those with mitral valve infection (n=9, P=0.10). The major pathogens were Staphylococcus aureus (4 cases) and Aspergillus fumigatus (3 cases). Factors associated with S. aureus infection were new hemodialysis catheters, cellulitis, and a contaminated donor organ. All patients with A. fumigatus had antecedent cytomegalovirus viremia and disseminated fungal infection, including endophthalmitis. Endocarditis-related mortality was 80%. Median survival after transplant was 1.4 years in patients with endocarditis, compared with 9.3 years in other heart transplant recipients (P<0.001).

CONCLUSIONS

Endocarditis is substantially more common in heart transplant recipients than in general populations. Frequent central venous catheter access and multiple endomyocardial biopsies appear to predispose to infection. Aspergillus is a common pathogen and endocarditis follows infection elsewhere. The prognosis of post-cardiac transplant endocarditis is poor.

Nosocomial infective endocarditis in critically ill patients: a report of three cases and review of the literature

Nosocomial infective endocarditis (NIE) is a relatively uncommon but nevertheless a serious complication affecting critically ill hospitalized patients who are frequently exposed to life-saving invasive procedures. We report three cases of NIE in a tertiary-care hospital encountered during a period of two years. The first case developed in a 50% burn-injured patient; the second in a liver transplant recipient; and the third in a renal transplant recipient. All patients met indications for cardiac surgical intervention, however, the patient who had received a liver transplant (case 2) was considered a poor candidate and unfit for surgery; she subsequently died. The other two patients underwent open-heart surgery. The burns patient (case 1) survived; conversely, the renal transplant recipient (case 3) died postoperatively. We have reviewed the literature concerning NIE in critically ill patients and describe the epidemiology, microbiology and clinical features of this uncommon infection and comment on its diagnosis and management.

Successful treatment of vancomycin-resistant Enterococcus faecium endocarditis with linezolid in a renal transplant recipient with human immunodeficiency virus infection

Infections with vancomycin-resistant Enterococci cause significant morbidity and mortality in hospitalized patients, including transplant recipients. We report the successful use of oral linezolid to treat a case of vancomycin-resistant Enterococcus faecium endocarditis in a renal transplant recipient with human immunodeficiency virus infection.

Fungal endocarditis

Recent advances in medicine have caused fungal endocarditis (FE) to be a more common disease entity. Many fungi are potential pathogens in FE, although Candida species and Aspergillus species are the most common. Valvular heart disease is the necessary underlying condition for FE, with intravenous devices and antibiotic use being the predisposing factors for yeast endocarditis, whereas immunosuppression in patients with valvulopathy predisposes for mold endocarditis. Better prognosis of FE depends on fast and accurate diagnosis and subsequent treatment. Echocardiography was the most valuable recent technique in the past two decades that allowed early diagnosis of FE and is probably responsible for the improved prognosis of patients with FE. In the future, development of nonculture-based diagnostic tests may further improve the sensitivity, specificity, and rapidity of microbiologic diagnosis of FE. Novel approaches in treatment, such as new antifungal drugs, also may assist in achieving cure and further improving the prognosis of this disease entity.

New clinical presentations of invasive aspergillosis in non-conventional hosts

Infections by Aspergillus spp. are most typically associated with invasive pulmonary aspergillosis. However, an increasing number of reports deal with unusual manifestations of invasive aspergillosis. In the lung this may take the form of chronic invasive pulmonary aspergillosis, bronchocentric granulomatosis or tracehobronchitis. A number of extrapulmonary infections have been noted, sometimes in immunocompetent individuals. Examples include vertebral osteomyelitis, primary cutaneous aspergillosis (such as in premature neonates), prosthetic vascular graft infection and infective endocarditis. Early recognition of these entities, prompt initiation of new, highly active antifungal therapies and adjunctive surgical management may improve the prognosis of these conditions.

Infective Endocarditis in Patients with Kidney Failure: Chronic Dialysis and Kidney Transplant

Physicians who treat patients with infective endocarditis (IE) are encountering a growing number of dialysis and kidney transplant patients. Both groups have 30 to 100 times higher risk of IE, with 1-year mortalities of 40% to 60%. The predominant organisms causing IE are gram positive, with 60% to 80% of cases due to Staphylococcus aureus, and another 10% to 20% of cases due to coagulase-negative staphylococci. Renal transplant patients may develop fungal IE, but this risk is primarily in the first 3 months after transplant. In addition to blood cultures, transesophageal echocardiogram is the most useful diagnostic examination for IE in these patients. Initial antibiotic therapy, pending final culture and antibiotic susceptibility results, should provide coverage against the most common organisms and allow for the potential of either methicillin or vancomycin-resistant species. Removal of infected hemodialysis access devices and at least 4 to 6 weeks of intravenous antibiotics are recommended. Antibiotic prophylaxis against IE has been recommended for all dialysis and renal transplant patients, but this strategy is controversial and unproven.