2023 ESC Guidelines for the management of endocarditis

Survival After Endocarditis Surgery Needing Venoarterial Extracorporeal Membrane Oxygenation Support: Results from the Netherlands Heart Registration

The incidence of venoarterial extracorporeal membrane oxygenation (VA-ECMO) support after cardiac surgery ranges from 0.4% to 3.7%, with in-hospital mortality rates reported at 60%. While the incidence of VA-ECMO after endocarditis (IE) surgery is unknown, these patients may face an even greater mortality risk due to additional IE-related complications. The primary objective of this study is to investigate the incidence and mortality rates of postoperative VA-ECMO following endocarditis surgery. The secondary objective is to compare clinical outcomes and to identify factors associated with in-hospital mortality in patients requiring and not requiring VA-ECMO support. Data were retrieved from the Netherlands Heart Registration. Of 3,468 IE surgeries performed between 2013 and 2022, 49 patients (1.4%) received postoperative VA-ECMO. The in-hospital mortality rate was 49% and the 1-year mortality rate was 60.9%. As expected, this was significantly higher compared to patients not requiring VA-ECMO support (49.0% vs 9.8% and 60.9% vs 15.2% respectively; p <0.001). At baseline, VA-ECMO patients had statistically higher rates of previous valve surgery, peripheral vascular disease and pulmonary hypertension, as well as lower renal and left ventricular functions compared to than patients not requiring VA-ECMO support. In addition, VA-ECMO patients more frequently underwent emergency surgeries and required aortic root surgery and coronary artery bypass grafting more often. While several comorbidities were associated with in-hospital mortality in patients not requiring VA-ECMO, no such associations were observed in VA-ECMO patients. In conclusion, while the incidence of VA-ECMO support after IE surgery is low, it comes with high mortality rates. However, mortality rates do not seem to differ from those reported for non-IE postcardiotomy VA-ECMO patients in current literature, and mortality after VA-ECMO support remains difficult to predict. Based on our data, postcardiotomy VA-ECMO should not be withheld from IE patients because of high-anticipated mortality risk.

Infective Endocarditis

The incidence of infective endocarditis (IE) is rising with the increased availability of prosthetic valves and intracardiac devices. In this review, we describe the epidemiologic trends, microbiology, and clinical manifestations of IE. The 2023 Duke-International Society for Cardiovascular Infectious Disease criteria are summarized, as are other laboratory and imaging studies that may aid in IE diagnosis, including novel methods like broad-range bacterial polymerase chain reaction and PET/computed tomography scans. Finally, we discuss optimal IE management, including guideline-directed antibiotic regimens, indications for cardiac surgery, and preliminary data for oral and long-acting parenteral antibiotics.

Minimally Invasive Valve Surgery for Patients With Infective Endocarditis: A Comparative Study

BACKGROUND

Patients with endocarditis frequently require valve surgical procedure, and despite the recent growth of minimally invasive cardiac surgery (MICS) for complex valve operations, consensus recommendations still suggest conventional sternotomy.

METHODS

The institutional Adult Cardiac Surgery Database of The Society of Thoracic Surgeons (STS) evaluated all patients undergoing valve surgical procedure for endocarditis from July 2016 to March 2024. Patients were stratified by conventional sternotomy vs an MICS approach, including hemisternotomy, right thoracotomy, and robotic-assisted mitral, tricuspid, or aortic valve surgical procedure. Logistic regression assessed the risk-adjusted association with the primary outcomes of STS major morbidity or mortality and the MICS approach by accounting for all covariates in current STS risk models.

RESULTS

Of 741 patients undergoing valve surgical procedure for endocarditis, the median age was 37 years, 582 (78.5%) had a substance use disorder, 210 (28.3%) underwent redo sternotomies, and 166 (22.4%) had redo valve operations. MICS was associated with a higher repair rate for mitral valves (76.3% vs 48%; P < .0001) but a lower rate for tricuspid valve (22.5% vs 44.1%; P < .0001), with no difference for aortic valves (8.3% vs 7.4%; P = .372). Before risk adjustment, MICS was associated with longer cross-clamp times (99 minutes vs 86 minutes; P = 0.019) but a lower incidence of STS major morbidity or mortality (15.4% vs 27.8%; P = 0.019). After robust risk adjustment, age (odds ratio [OR], 1.1; P = 0.008), lung disease (OR, 2.2; P = 0.010), preoperative creatinine (OR, 1.3; P = 0.016), and valve repair vs replacement (OR, 0.17; P = 0.002), but not MICS (OR, 1.2; P = 0.807), were independently associated with STS major morbidity and mortality.

CONCLUSIONS

MICS valve surgical procedure for endocarditis appears both safe and effective, with repair rates and risk-adjusted outcomes similar to those of open surgical procedure.

Trends in infective endocarditis over two decades in a Thai tertiary care setting

Infective endocarditis (IE) is a serious condition with high morbidity and mortality. This retrospective cohort study evaluated the evolution of clinical characteristics, microbiological profiles, and treatment outcomes in 435 Thai IE patients, spanning three distinct periods, at a Chiang Mai tertiary-care hospital. Patients were categorized into three timeframes: 1998-2001 (n = 134), 2012-2015 (n = 117), and 2016-2020 (n = 184). The median patient age significantly increased from 42 years (IQR 34-51) to 58 years (IQR 44-65) (p = 0.003). The study also identified an increased prevalence of co-morbidities in recent years. Notably, there was a marked decrease in the prevalence of rheumatic heart disease, from 23.1 to 10.9% (p = 0.009). Streptococcus suis is a unique and increasingly prevalent cause of IE in northern Thailand. Additionally, the rate of culture-negative IE declined from 38.1 to 23.9% (p = 0.018). Surgical interventions increased from 52.2 to 64.1% (p = 0.072), while the median time to surgery remained constant at 12 days. Despite advancements in diagnosis and treatment, the length of hospitalization remained stable throughout the study periods, and the in-hospital mortality rate consistently stayed at 18.6%. This study highlights significant shifts in the epidemiology and management of IE, indicating persistent challenges in reducing mortality despite improved care.

Role of percutaneous mechanical aspiration for right-sided endocarditis in people who inject drugs

The incidence of isolated right-sided endocarditis has increased in recent years. Patients who inject drugs are an important demographic of this population. However, recent literature suggests these patients have substantially worse medium-term outcomes despite initially successful surgery. Ongoing opioid addiction is felt to be an important contributor. Early surgery is often aimed at source control and limiting infectious complications. Percutaneous transvenous mechanical aspiration is a novel technique that can achieve source control without causing significant acute or chronic pain, leading to rapid adoption of this tool. This article outlines its evolving role in right sided endocarditis.

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.

Blood Culture-Negative Endocarditis: A Scientific Statement From the American Heart Association: Endorsed by the International Society for Cardiovascular Infectious Diseases

Blood culture-negative endocarditis has been associated with worse outcomes when compared with blood culture-positive endocarditis, because pathogen-directed antimicrobial therapy and other management aspects have been difficult to achieve. Novel diagnostic tools, however, have changed the landscape of this syndrome and will likely improve patient outcomes. This American Heart Association scientific statement highlights these advances. The writing group, which represents a multidisciplinary team, provides an update on blood culture-negative endocarditis. Clinical scenarios representative of real-world experiences are included to assist frontline clinicians in the diagnosis and management of this syndrome.

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.

Clinical features and medical-surgical management overweight the inoculum effect and genotypic characteristics of MSSA in infective endocarditis

OBJECTIVES

MSSA remains the leading cause of infective endocarditis (IE) and is responsible for significant mortality. While clinical factors tied to mortality are well documented, possible contributing strain-specific characteristics have not been extensively explored. This study investigates MSSA phenotypic and genotypic characteristics and medical-surgical data related to Day-90 mortality in IE.

METHODS

We included all patients enrolled in a monocentric prospective cohort (2016-23), with definite or probable MSSA IE. Cefazolin and oxacillin MICs and inoculum effects were determined by broth microdilution. Genotyping analysis and BlaZ typing were obtained from WGS. Phenotypic and genotypic characteristics of strains and clinical risk factors were confronted with Day-90 mortality.

RESULTS

Eighty-eight patients with MSSA IE were included. The most frequent clinical presentations were left-sided native valve IE (25/88), left-sided prosthetic valve IE (12/88) and right-sided IE (19/88). Day-90 mortality rate was 39% (34/88). Most patients were treated with antistaphylococcal penicillin as a primary antibiotic (60/88). The main MSSA clonal complexes identified were CC398 (17/88), CC30 (13/88) and CC5 (13/88). Cefazolin inoculum effect was observed in 18/88 strains, and oxacillin inoculum effect in 13/88. Overall, 15/88 isolates exhibited an inoculum effect on primary antibiotic therapy. Factors independently associated with improved outcomes included cardiac surgery [hazard ratio (HR) 0.34, 95% CI (0.13-0.89)] and source control [HR 0.21, 95% CI (0.03-0.53)]. Neither genetic background, blaZ carriage, nor in vitro inoculum effect to the primary antibiotherapy was associated with Day-90 mortality.

CONCLUSIONS

This cohort of MSSA IE did not find any microbiological factors correlated with Day-90 mortality. Clinical features and infection management appear to be the main factors in the prognosis of MSSA IE.

Management of methicillin-resistant Staphylococcus aureus bloodstream infections: a comprehensive narrative review of available evidence focusing on current controversies and the challenges ahead

INTRODUCTION

Bloodstream infections (BSIs) caused by Staphylococcus aureus are common worldwide, representing one of the most relevant issues in clinical infectious diseases practice. In particular, BSIs by methicillin-resistant S. aureus (MRSA-BSI) are still today a challenge since mortality burden remains elevated although decades of research.

AREAS COVERED

The following topics regarding MRSA-BSI were reviewed and discussed by resorting to best available evidence retrieved from PubMed/MEDLINE up to October 2024: i) epidemiology; ii) microbiology; iii) classification, with a focus on complicated and not complicated forms; iv) the structured approach to the patient; v) pharmacokinetics and pharmacodynamics of the main antimicrobial options; vi) controversies regarding the best therapeutic approach.

EXPERT OPINION

Despite ongoing efforts to better stratify and manage MRSA-BSI, there is no universally accepted classification system accurately distinguishing between uncomplicated/low risk and complicated/high risk forms. Biomarkers such as interleukin(IL)-10 hold promise in order to enable a more precise stratification, premise for an appropriate treatment plan. There is a theoretical rationale for implementing a combination therapy including a beta-lactam agent upfront, especially for patients considered at higher risk of unfavorable outcomes, but further data are necessary, and the same applies to newer adjuvants. Novel microbiological techniques may help in guiding antimicrobial duration.

Serum lactate dehydrogenase level as a predictor of 28-day mortality in critically ill patients with infective endocarditis: a retrospective cohort study from MIMIC IV database

BACKGROUND

Infective endocarditis (IE) is a serious infectious disease with a rising incidence rate and high mortality rate. While lactate dehydrogenase (LDH) is a sensitive and accessible biomarker of inflammation, tissue damage and metabolic alteration, its prognostic value in IE remains unexplored.

OBJECTIVE

This study aims to investigate the prognostic value of admission serum LDH levels for 28-day mortality in critically ill IE patients.

METHODS

The data used in this retrospective cohort study was extracted from the MIMIC-IV database. Restricted cubic spline analysis, Cox regression, Kaplan-Meier survival analysis, and receiver operating characteristic analysis were performed to evaluate the predictive value of serum LDH in critically ill IE patients. Key clinical confounders for the adjusting Cox models were filtered by LASSO regression.

RESULTS

A total of 215 critically ill patients with diagnosed IE were included during their first intensive care unit admission. LDH was one of the most significant confounders identified by LASSO analysis. The crude and adjusted Cox models revealed a consistently independent and dose-response relationship between high serum LDH and higher mortality. The fully adjusted model showed each standard deviation increase in LDH (log2) was associated with a hazard ratio of 2.37 (95% CI: 1.51-3.71, p < 0.001). Kaplan-Meier curves demonstrated significantly different survival patterns across LDH levels (p = 0.0032). The area under the curve (AUC) of LDH was higher than SOFA score (AUC=0.637 v.s. 0.573, p=0.251).

CONCLUSION

This study identified serum LDH as an independent predictor of mortality in critically ill IE patients.

A novel approach to studying infective endocarditis: Ultrasound-guided wire injury and bacterial challenge in mice

BACKGROUND

Infective endocarditis (IE) is frequently caused by Staphylococcus aureus (S. aureus) and most commonly affects the aortic valve. Early diagnosis and treatment initiation are challenging because the involved immunological processes are poorly understood due to a lack of suitable in vivo models.

OBJECTIVES

To establish a novel reproducible murine IE model, based on ultrasound-guided wire injury (WI) induced endothelial damage.

METHODS

IE was established by inducing endothelial damage via ultrasound-guided wire injury followed by bacterial challenge with S. aureus using 104-6 colony-forming units (CFU) 24h to 72h after wire injury. Cross-sections of valvular leaflets were prepared for scanning electron microscopy (SEM) and immunofluorescence microscopy to visualize valvular invasion of macrophages, neutrophils, and S. aureus. Bacterial cultivation was carried out from blood and valve samples. Systemic immune response was assessed using flow cytometry.

RESULTS

Wire injury induced endothelial damage was observed in all mice after wire-injury in SEM imaging. We reliably induced IE using 105 (85%) and 106 (91%) CFU S. aureus after wire injury. Aortic regurgitation was more prevalent in wire injury mice after bacterial challenge. Mice undergoing bacterial challenge responded with significant neutrophilia and elevated pro-inflammatory cytokines in the blood. Immunofluorescence staining revealed significantly increased immune cell accumulations using our proposed model compared to controls.

CONCLUSION

Echocardiography and ex vivo histological staining demonstrated consistent infective endocarditis induction in our new model, combining a wire injury-induced endothelial damage and S. aureus administration. Further exploration of the initial immune cell response and biomarker expression could potentially identify indicators for early IE diagnosis and novel treatment targets.

Management of Staphylococcus aureus Bacteremia: A Review

Importance

Staphylococcus aureus, a gram-positive bacterium, is the leading cause of death from bacteremia worldwide, with a case fatality rate of 15% to 30% and an estimated 300 000 deaths per year.

Observations

Staphylococcus aureus bacteremia causes metastatic infection in more than one-third of cases, including endocarditis (≈12%), septic arthritis (7%), vertebral osteomyelitis (≈4%), spinal epidural abscess, psoas abscess, splenic abscess, septic pulmonary emboli, and seeding of implantable medical devices. Patients with S aureus bacteremia commonly present with fever or symptoms from metastatic infection, such as pain in the back, joints, abdomen or extremities, and/or change in mental status. Risk factors include intravascular devices such as implantable cardiac devices and dialysis vascular catheters, recent surgical procedures, injection drug use, diabetes, and previous S aureus infection. Staphylococcus aureus bacteremia is detected with blood cultures. Prolonged S aureus bacteremia (≥48 hours) is associated with a 90-day mortality risk of 39%. All patients with S aureus bacteremia should undergo transthoracic echocardiography; transesophageal echocardiography should be performed in patients at high risk for endocarditis, such as those with persistent bacteremia, persistent fever, metastatic infection foci, or implantable cardiac devices. Other imaging modalities, such as computed tomography or magnetic resonance imaging, should be performed based on symptoms and localizing signs of metastatic infection. Staphylococcus aureus is categorized as methicillin-susceptible (MSSA) or methicillin-resistant (MRSA) based on susceptibility to β-lactam antibiotics. Initial treatment for S aureus bacteremia typically includes antibiotics active against MRSA such as vancomycin or daptomycin. Once antibiotic susceptibility results are available, antibiotics should be adjusted. Cefazolin or antistaphylococcal penicillins should be used for MSSA and vancomycin, daptomycin, or ceftobiprole for MRSA. Phase 3 trials for S aureus bacteremia demonstrated noninferiority of daptomycin to standard of care (treatment success, 53/120 [44%] vs 48/115 [42%]) and noninferiority of ceftobiprole to daptomycin (treatment success, 132/189 [70%] vs 136/198 [69%]). Source control is a critical component of treating S aureus bacteremia and may include removal of infected intravascular or implanted devices, drainage of abscesses, and surgical debridement.

Conclusions and relevance

Staphylococcus aureus bacteremia has a case fatality rate of 15% to 30% and causes 300 000 deaths per year worldwide. Empirical antibiotic treatment should include vancomycin or daptomycin, which are active against MRSA. Once S aureus susceptibilities are known, MSSA should be treated with cefazolin or an antistaphylococcal penicillin. Additional clinical management consists of identifying sites of metastatic infection and pursuing source control for identified foci of infection.

Infective endocarditis and the association to income as a proxy for socioeconomic position - A Danish nationwide register-based cohort study

AIMS

Despite continued focus on infective endocarditis morbidity and mortality remains high. Socioeconomic position is known to influence the risk of multiple diseases but the impact on the occurrence of infective endocarditis is unknown. We aimed to investigate the association between available income as a proxy for socioeconomic position and infective endocarditis in an unselected nationwide population.

METHODS AND RESULTS

By cross-linking Danish nationwide registers, we identified all Danish residents above 30 years of age, from January 1st, 2007 through December 31st, 2017. Information on income, comorbidities and the primary outcome of infective endocarditis was obtained through the registers. Socioeconomic position was defined according to quintiles of disposable income. The association between socioeconomic position and infective endocarditis was examined using multivariate Poisson Regression analyses, incorporating time-updated estimates of disposable income. The study included 3,524,314 individuals (median age = 47 years) with a median follow-up of 11 years. Declining level of income was associated with increasing incidence rates of infective endocarditis, spanning from 7-20 events/100.000 person-years. Individuals with low income had higher incidence rate ratio (IRR) of infective endocarditis compared to individuals with high income (lowest vs. highest income group, IRR = 1.58 [1.43-1.75]). The association between decreasing income and increasing IRR of infective endocarditis was present across all age groups, although the association was strongest in the young population.

CONCLUSION

In a nationwide population, a significant association between low income and increasing incidence of infective endocarditis was observed. The association was most evident in younger individuals.

Population pharmacokinetics and optimized prophylaxis dosing of cefazolin during transcatheter aortic valve implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical valve replacement for aortic stenosis. Infective endocarditis, most often caused by enterococci, is a significant post-procedural complication. Cefazolin has been the most frequently utilized agent for TAVI procedural prophylaxis, although recent guidelines suggest addition of an agent with enterococcal activity. Optimizing antimicrobial prophylaxis is important but little is known about antibiotic pharmacokinetics (PK) in this procedure.

OBJECTIVES

To define the population PK profile of prophylactic cefazolin in TAVI procedures and determine appropriateness for use.

METHODS

Adult patients receiving cefazolin prophylaxis for TAVI were enrolled. Serum was collected at four timepoints periprocedurally for analysis of cefazolin concentrations. Population PK analysis and Monte Carlo simulation was performed. Fractional target attainment (FTA) against MIC distributions for common pathogens was performed.

RESULTS

Three hundred and fifty-nine plasma cefazolin concentrations (188 total, 171 unbound) from 50 participants were used for model development. PTA for a 2 g dose of cefazolin and a procedure of 2 h duration was >90% for organisms with an MIC up to 8 mg/L. FTA was 100% for MSSA at all examined procedure durations and estimated glomerular filtration rate levels. FTAs for Staphylococcus epidermidis and Enterococcus faecalis, based on limited MIC data, were predominantly subthreshold.

CONCLUSIONS

This study found a 2 g dose of cefazolin achieved target exposure for MSSA but was subthreshold for other pathogens.

Contemporary cohort study in adult patients with infective endocarditis

BACKGROUND

Infective Endocarditis (IE) is a serious disease, with high morbidity and mortality. Few case series come from middle- income countries. Our aim is to describe a case series of patients with IE treated at a reference center in Brazil and compare data to other countries.

METHODS

A retrospective analysis of a prospectively implemented endocarditis database was conducted, including adult patients with definite IE, January 2006‒June 2023. A literature search and summary were done. Statistical analysis was performed using Jamovi®, version 1.2.2.

RESULTS

There were 502 episodes of IE; mean age ± SD was 48.4±17.2 years. Community-acquired IE occurred in 64.7 %. Main predispositions were rheumatic valve disease (30.7 %), prostheses (31.5 %), and congenital heart disease (13.9 %). Transthoracic and transesophageal echocardiograms were performed in 85 % and 78 %, respectively. Left-sided IE predominated. Fever occurred in 90.6 %, new murmurs in 50.7 %, and embolism in 45 %. Blood cultures were negative in 33.1 %; frequent pathogens were oral streptococci (15.6 %), Staphylococcus aureus (10.0 %), and enterococci (12.8 %). Main complications were heart failure (58 %), renal failure (32.8 %), and splenic embolization (35.2 %). Surgery was performed in 83.6 %; overall in-hospital mortality was 25 %; surgical mortality was 21.3 %.

CONCLUSIONS

Blood culture negative left-sided IE predominated. The mortality rate was high but within the range of reported series. Surgery was performed frequently and patients who were operated on had lower mortality.

1-Year Outcomes of PT-Valve for Pulmonary Regurgitation in Native Outflow Tract

BACKGROUND

Severe pulmonary regurgitation (PR) in patients with postoperative congenital heart disease is often accompanied by extensive variability of right ventricular outflow tract (RVOT) anatomy, which limited the wide application of existing transcatheter pulmonary valves device.

OBJECTIVES

This study sought to evaluate 1-year safety and efficacy of the PT-Valve in the treatment of PR patients presenting with native RVOT from a multicenter, single-arm clinical trial.

METHODS

We enrolled 130 patients of moderate or greater PR. One-year clinical outcomes are reported.

RESULTS

Within the cohort (mean age 30 ± 16 years; 52% men), 124 (95%) were diagnosed with tetralogy of Fallot. The procedure success rate was 98.5%. Early explants occurred to 2 device malpositions and 1 pulmonary branch obstruction. At 1 year, there were no procedure- or device-related mortality. Device-related adverse events included 2 arrhythmias, 1 pulmonary thromboembolism, 2 endocarditis, and 1 vascular access complication. Echocardiography examinations showed that 125 (99%) patients had none/trace and mild PR, and no greater than mild paravalvular leak at 1-year visit. The mean peak pulmonary gradient was 20.0 ± 17.4 mm Hg and 16.0 ± 7.8 mm Hg at baseline and 1 year after implantation, respectively. The right ventricular end-diastolic volume index was reduced from 176.3 ± 28.4 mL/m2 at baseline to 121.1 ± 20.7 mL/m2 at 1 year (P < 0.001).

CONCLUSIONS

The PT-Valve demonstrated a high success rate of implantation and favorable safety and efficacy in the treatment of PR through 1 year. This device is anatomically suitable for more than 90% of PR patients with native RVOT. (Prospective, Single Arm, Multi-Center Clinical Study on the Safety And Efficacy of the Sterile Transcatheter Pulmonary Valve and Delivery System; ChiCTR2100043367).

Real-World Use, Effectiveness, and Safety of Intravenous Fosfomycin: The FORTRESS Study

INTRODUCTION

Intravenous fosfomycin (FOS) is a broad-spectrum antibiotic primarily used in combination therapy to treat severe infections caused by both Gram-positive (GP) and Gram-negative (GN) pathogens, including multi-drug resistant (MDR) bacteria. The aim of this study, the largest to date, was to evaluate the effectiveness, safety, usage patterns, and patient characteristics of FOS in a real-world setting.

METHODS

Interim analysis of an ongoing, prospective, non-interventional, multicentre study in five European countries, involving centres in Germany, Italy, the United Kingdom, Greece, and Austria.

RESULTS

A total of 716 patients were enrolled between January 2017 and November 2023 (mean age: 62.8 years, APACHE II: 18.3, SOFA: 6.7). Main indications for FOS were bacteraemia/sepsis (23.6%), complicated urinary tract infections (18.0%), and bone and joint infections (17.4%). Other indications included hospital-acquired/ventilator-associated pneumonia (11.0%), complicated skin and soft tissue infections (9.1%), bacterial meningitis/central nervous system (CNS) infections (7.8%), and infective endocarditis (6.4%). Most common pathogens identified were Staphylococcus aureus (31.4%, including methicillin-resistant S. aureus), Klebsiella spp. (including K. pneumoniae) (17.2%), Escherichia coli (14.2%), coagulase-negative staphylococci (12.9%), other Enterobacterales (10.9%), and Pseudomonas aeruginosa (8.4%). In 34.6% of patients, an MDR pathogen was involved. Carbapenem resistance (CR) was high in Klebsiella spp. infections (59/123, 48.0%). In most patients, FOS was used in combination therapy (90.2%). The median dose was 15 g/day. Overall, clinical success and clinical response were favourable with 75.3% and 83.4% at the end of FOS treatment. Clinical success rates in infections caused by MDR or CR pathogens were 78.0% and 81.8%, respectively. Microbiological cure was achieved in 82.4% of all patients. Electrolyte imbalances were the most frequently observed adverse drug reactions, while gastrointestinal disorders were rare.

CONCLUSION

The results from this study suggest that FOS is a safe and effective option as combination partner in the treatment of patients with severe infections caused by both GP and GN pathogens, including deep-seated infections and/or involvement of MDR bacteria.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT02979951.

Vertebral osteomyelitis in patients with infective endocarditis: prevalence, risk factors and mortality

PURPOSE

Infective endocarditis (IE) can be complicated by vertebral osteomyelitis (VO). This study investigates risk factors associated with VO in patients with infective endocarditis, and 6-month mortality and relapse rates in patients with IE and concomitant VO.

METHODS

We performed a observational study in two hospitals between September 2016 and October 2022. Patients with possible or definite IE according European Society of Cardiology (2015) modified criteria were retrieved from the local endocarditis team registries. The VO diagnosis was based on radiological signs, irrespective of clinical symptoms. Multivariable logistic regression analysis was performed to identify risk factors for vertebral osteomyelitis.

RESULTS

We included 633 consecutive patients with IE. A total of 229 (36.2%) patients had prosthetic valves and 127 (20.1%) had cardiac implantable electronic devices. The most frequent causative micro-organism was Streptococcus species (217, 34.3%), followed by Staphylococcus aureus (167, 26.4%). VO was diagnosed in 73 patients (11.5%, 95% CI 9.0%-14.0%). Enterococcus spp.(OR 2.48, 95% CI 1.31-4.52) and age (OR 1.04 per year, 95% CI 1.02-1.06) were independently associated with concomitant VO. The 6-month mortality risk did not differ between patients with (16/73, 21.9%) or without (110/560, 19.6%) VO (HR 1.13, 95% CI 0.67-1.91). Relapse rate was higher in patients with VO but the difference was not statistically significant (16.1 vs. 7.5%, OR 3.62, 95% CI 0.94-13.34).

CONCLUSIONS

Twelve percent of patients with IE also had VO. Among older patients and patients with IE caused by enterococci, there should be a higher index of suspicion for vertebral infection.

Clinical presentation, treatment, and antimicrobial susceptibility of 155 sequential Staphylococcus lugdunensis infections

Staphylococcus lugdunensis is known to be virulent, but there are few large-scale epidemiologic studies of this species to define types of infection, susceptibility patterns, and severity. S. lugdunensis isolates from any culture at four U.S. tertiary care hospitals between 1 April 2021 and 1 April 2022 were identified. For the first isolate from each subject, clinical, demographic, and outcome data were recorded. Of 291 isolates, 223 were obtained from a clinically significant infection. Of these 223 isolates, 86 (38.6%) were from monomicrobial cultures; additionally, S. lugdunensis was considered a true pathogen in 69/137 polymicrobial infections. Among 155 subjects with S. lugdunensis infections, 49.7% were female, 46.5% were black, and 41.9% were white; 51.6% of infections were community associated. The most common infection sites were skin and soft tissue (SSTI) (n = 98, 63.2%), urinary tract (n = 16, 10.3%), and sinusitis (n = 14, 9%). Of nine monomicrobial bloodstream infections (BSIs), two were fatal, three involved foreign bodies, and two had infective endocarditis. Greater than half of SSTIs required an invasive procedure for cure. Among 138/291 isolates from colonization or infection, tetracycline, trimethoprim-sulfamethoxazole, oxacillin, and vancomycin susceptibility rates were 94.8% (128/135), 95.9% (94/98), 84.1% (116/138), and 100% (138/138), respectively. There were similarities in types of infection comparing S. lugdunensis in this study and prior reports on Staphylococcus aureus. SSTI was the predominant S. lugdunensis infection type; more than 50% of SSTIs required procedural intervention. Of nine BSIs, three involved a foreign body, and there were two cases of infective endocarditis. Oxacillin resistance was identified in 16% of isolates.

IMPORTANCE

In recent years, Staphylococcus lugdunensis has been identified with increasing frequency as a human pathogen causing a wide variety of clinical syndromes, from soft tissue infections to fatal cases of bloodstream infection. Despite this, there are few large-scale epidemiologic studies examining this highly virulent organism. Our study adds to the growing literature on this emerging pathogen by analyzing a large case series of sequential S. lugdunensis infections at four U.S. hospitals to define its contemporary epidemiology, including the types of infections it causes, their outcomes, treatment approaches, and antimicrobial susceptibilities. These data provide valuable insights for clinicians in diagnosing and treating patients with these often debilitating infections. The findings also improve upon our understanding of the incidence of each infection syndrome and variability in antimicrobial susceptibilities of isolates to guide the design of future studies on the genomic epidemiology of this important pathogen.

Introducing the use of AngioVac in nonbacterial thrombotic endocarditis: a systematic review

INTRODUCTION

Nonbacterial thrombotic endocarditis (NBTE) involves vegetations on heart valves without active bloodstream infection. The AngioVac device, a vacuum-based aspiration system commonly used for infective endocarditis, has potential in managing NBTE, particularly in patients unsuitable for surgery. This study systematically reviews the literature to evaluate AngioVac's effectiveness in reducing vegetations in NBTE.

METHODS

A systematic literature review was conducted using PubMed, Embase, Cochrane, and Web of Science databases through February 2024. Primary outcome was procedural success, defined as a ≥ 50% reduction in vegetation size on transesophageal echocardiogram. Secondary outcomes included in-hospital mortality, hospital stay length, and procedural complications.

RESULTS

Out of 38 identified articles, 4 case reports met inclusion criteria. Patients were male with a median age of 60 years, and NBTE was associated with conditions such as lung adenocarcinoma, end-stage renal disease, and antiphospholipid syndrome. The mitral valve was the most commonly affected site. AngioVac achieved 100% procedural success, with no complications or in-hospital mortality. The average hospital stay was 2 days. Follow-up revealed one patient alive at 2 months, one deceased at 3 months and no data for two patients.

CONCLUSION

AngioVac is a promising tool for safely reducing vegetations in NBTE, especially for high-risk surgical candidates.The study design and protocol are registered with PROSPERO International Prospective Register of Systematic Reviews (registration number CRD42024505295).

Transcatheter aortic valve implantation: Association between skin flora and infective endocarditis?

BACKGROUND

Infective endocarditis is a rare but severe complication that may arise following transcatheter aortic valve implantation. Recent advances in microbiological epidemiology have highlighted staphylococci and enterococci as the primary pathogens involved.

AIM

To investigate the prevalence of these bacteria in patients' cutaneous flora before and after transcatheter aortic valve implantation procedures, and to assess the implications for antibiotic prophylaxis recommendations.

METHODS

A single-centre prospective epidemiological study was conducted, enrolling patients admitted consecutively for transcatheter aortic valve implantation procedures between June 2021 and February 2022. Cutaneous samples were obtained from each patient at the puncture site of the transcatheter aortic valve implantation procedure, before and after skin detersion, and from operator hands after skin detersion.

RESULTS

One hundred patients were included, with a mean age of 82±6.1years, a male-to-female ratio of 0.48 and a mean body mass index of 29±4.4kg/m2. Before skin detersion, cutaneous samples were positive in 58 patients; among them were coagulase-negative staphylococci (n=48, 82%, 95% confidence interval 71-91%), enterococci (n=12, 21%, 95% confidence interval: 11-33%), Staphylococcus aureus (n=2, 3%, 95% confidence interval 0-12%) and Enterobacteriaceae (n=4, 7%, 95% confidence interval: 2-17%).

CONCLUSIONS

Enterococci are frequently present in patients' cutaneous flora at the puncture site before skin detersion, suggesting a potential source for infective endocarditis after transcatheter aortic valve implantation. These findings support considering amoxicillin-clavulanate as antibiotic prophylaxis before transcatheter aortic valve implantation procedures to mitigate the risk of infective endocarditis associated with enterococcal colonization.

Non-bacterial thrombotic endocarditis masquerading as infective endocarditis: a paraneoplastic process

A 76-year-old lady presented to her local hospital with chest pain, malaise, and fever, suspected to be due to infective endocarditis. Echocardiography showed a mass on the anterior mitral valve leaflet. Multimodal imaging showed several suspected systemic septic emboli. CT showed multiple hepatic lesions and a cavitating pulmonary lesion. Magnetic resonance imaging revealed multiple cerebral lesions. Dual antibiotic treatment was commenced, though this was unsuccessful, with persistence of her symptoms. She was therefore transferred to our tertiary centre for emergency cardiac surgery. She underwent successful bioprosthetic mitral valve replacement and initially made a good post-operative recovery. However, on the fifth post-operative day, she decompensated. Transoesophageal echocardiography showed extensive thromboses on the bioprosthetic mitral valve leaflets, in the left atrium and inferior vena cava, and on the aortic valve. Subsequently, a hepatic biopsy was performed revealing metastatic adenocarcinoma. The patient unfortunately passed away shortly after, and post-mortem examination confirmed a pulmonary adenocarcinoma with hepatic and cerebral metastases. This case highlights the importance of considering paraneoplastic processes in such cases of suspected infective endocarditis with atypical features.

Incidence and outcomes of prosthetic valve endocarditis in adults with congenital heart disease

BACKGROUND

Patients with congenital heart disease (CHD) often require prosthetic valve implantation, increasing their lifetime risk of developing prosthetic valve endocarditis (PVE). The purpose of this study was to determine the incidence, risk factors, and outcomes of PVE in adults with CHD.

METHOD

Retrospective cohort study of adults with CHD and prior prosthetic valve implantation (2003-2023). Patients diagnosed with PVE were designated as the PVE group, while the patients without PVE were designated as the reference group.

RESULTS

Of 9161 patients, 3150 (34%) had prosthetic valves. Among the patients with prosthetic valve, 86 (2.7%) developed PVE, yielding an incidence of 5.2 (95% confidence interval [CI] 4.8-1-5.6) events per 1000 patient-years. Of the 86 patients with PVE, the average age at the time of PVE diagnosis was 35 ± 9 years, the average interval between prosthetic valve implantation and PVE was 91 ± 27 months, and mean duration of follow-up with11.6 ± 4.9 years. The risk factors for PVE were male sex, younger age, type 2 diabetes, multiple prosthetic valves, and Melody bioprosthetic valve implantation. PVE was associated with more than a 2-fold increase in all-cause mortality (adjusted hazard ratio 2.21, 95% CI 1.33-3.68, P = .002), after adjustment for demographic/anatomic indices, and comorbidities. Of 86 patients with PVE, 21 (24%) died during follow-up. The 30-day, 1-year, and 5-year mortality after diagnosis of PVE was 1.6%, 12% and 15%, respectively. Of 86 patients, 39 (45%) developed 47 PVE-related complications (perivalvular abscess[(n = 21], and septic emboli [n = 26]). PVE-related complications were associated with all-cause mortality.

CONCLUSIONS

PVE was common in CHD patients with prosthetic valves and was associated with all-cause mortality. These findings highlight the prognostic implications of prosthetic valve implantation in patients with CHD, and the need for new criteria for risk stratification in order to improve outcomes.

Recurrent isolated pulmonic valve infective endocarditis in a patient on chronic haemodialysis due to reinfection: description of an index case and management considerations

Background

Right-sided infective endocarditis is uncommon, and isolated pulmonic valve infective endocarditis (PVIE) is rare. Chronic haemodialysis is a risk factor for developing infective endocarditis. but recurrent PVIE in this population is not well described.

Case summary

A 32-year-old male with end-stage renal disease on chronic haemodialysis and diagnosed with PVIE 6 months back due to Staphylococcus epidermidis without identified source of infection presented again with recurrent PVIE with methicillin sensitive S. aureus, new pulmonic septic emboli, and peri-graft fluid collection on imaging, which was explanted with negative follow-up culture.

Discussion

Through this index case, we describe the unique pathology of recurrent isolated PVIE and explore its diagnostic and management considerations.

Postoperative Treatment Regimens in Patients With Native Valve Endocarditis due to Staphylococcus aureus Who Undergo Valve Replacement or Repair

Background

There remains a lack of consensus regarding the postoperative treatment regimen in patients with native valve Staphylococcus aureus infective endocarditis who undergo surgical valve replacement or repair.

Methods

We conducted a multicenter retrospective review of patients with S aureus native valve endocarditis who underwent surgical valve replacement or repair at Mayo Clinic Enterprise (Minnesota, Florida, Arizona, and Mayo Clinic Health Systems) between 1 January 2012 and 31 December 2022. Postoperative treatment regimens were classified as either monotherapy with a methicillin-sensitive or methicillin-resistant S aureus active agent or combination therapy that included rifampin and/or gentamicin with either active agent.

Results

Of the 339 patients diagnosed with S aureus native valve endocarditis, 61 underwent surgical valve replacement or repair within the initial 6 weeks of antimicrobial therapy. A total of 12 (20.2%) patients died during the 1-year follow-up period. Between patients postoperatively treated with monotherapy (n = 33) and combination therapy (n = 28), a propensity score-weighted analysis revealed that combination therapy was associated with increased risk of 1-year mortality (P = .039), 6-month relapse (P = .016), and treatment-related adverse events (P < .001).

Conclusions

Among patients treated for native valve infective endocarditis caused by S aureus after valvular surgical intervention, all study outcomes-adverse events and drug-drug interactions, 6-month infective endocarditis relapse, and 1-year mortality-were higher in the combination therapy group than the monotherapy group.

Non-surgical endodontic management for the medically complex - hints and tips for the general dental practitioner

The management of patients with additional medical complexities is challenging and can cause apprehension when considering if dental treatment is able to be provided in primary care. Non-surgical endodontic treatment is generally a low-risk procedure for many patient cohorts. This paper describes commonly seen medical conditions, the impact on bleeding and infection, and where extraction would preferably be avoided. It explores the risk assessment of these conditions and provides 'hints and tips' for the provision of endodontic treatment, allowing for the safe and effective provision of dental care, in the appropriate setting, by the appropriate specialty.

Economic burden of infective endocarditis in Zhejiang region from 2007 to 2016

BACKGROUND

Infective endocarditis (IE) has attracted widespread public attention. However, studies on its economic burden remain scarce.

METHODS

This retrospective study aimed to collect data on the clinical characteristics of patients with IE from electronic medical records and estimate the economic burden with disability-adjusted life years (DALYs). Additionally, the changing trend of IE from 2007 to 2016 and differences between native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) on economic burden were analyzed.

RESULTS

There were 407 patients with IE enrolled in this study. The total DALY loss was 1710.2. The average indirect economic burden ranged from $6253.27 to $14766.34 from 2007 to 2016 showing a stable trend, which was 1.67 to 2.46 times the annual per gross domestic product (GDP). Interestingly, the average indirect economic burden for females ranged from $5941.37 to $17261.07 with a significant upward trend during this period (P = 0.035).The average DALY loss and indirect economic burden were highest in patient aged ≤ 19 (4.82, $21486.12) and lowest in those aged 80-89(0.46, $342.87), decreasing significantly with age(both P<0.001). Finally, there were no significant differences in the average DALY loss and indirect economic burden between the PVE group and NVE group during this period (2.69 vs. 2.63, P = 0.740; $9224.0vs. $11789.4, P = 0.136).

CONCLUSIONS

The DALY loss and indirect economic burden associated with IE were notably high, particularly among younger patients and females. These findings highlight the need for targeted preventive care and early interventions, especially for youth and gender-specific strategies, to reduce disparities in IE burden.

Development of bacterial resistance in Germany from 2008 to 2022 - major culprit pathogens, antibacterial drugs, and prescribing practices

Rising bacterial resistance is a global threat, causing rising financial burdens on healthcare systems and endangering effective treatment of bacterial infections. To ensure the efficacy of antibacterial drugs, it is essential to identify the most dangerous pathogens and vulnerable antibacterial drugs. Previous research by our group suggested irrational outpatient prescribing practices in Germany, supporting a growing bacterial resistance. This study analyses developments and characteristics for the ten most prescribed antibacterial drugs in Germany from 2008 to 2022. Conclusions are based on the development of bacterial resistance levels and an analysis of correlations between pathogens. We identified cefuroxime axetil, sulfamethoxazole-trimethoprim and nitrofurantoin as the most problematic drugs. Particularly problematic pathogens include E. faecalis, E. faecium, K. pneumoniae, and P. mirabilis. Besides increasing bacterial resistance, they are characterised by a high proportion of significant positive correlations, indicating a high potential for mutually reinforcing resistance development. Alarmingly, most of the antibacterial drugs analysed showed a growing resistance to at least one of the analysed pathogens. In most cases, the best treatment option is threatened by increasing bacterial resistance. We also identified several differences between current bacterial resistance data and therapeutic guidelines. In aggregate, our findings support irrational prescribing behaviour and underscore the urgent need for improved prescribing practices to counter rising bacterial resistance in Germany. Moreover, therapeutic guidelines for bacterial infections, the "holy grail" of pharmacotherapy, must be updated more frequently.

Association between adjunctive rifampin and gentamicin use and outcomes for patients with staphylococcal prosthetic valve endocarditis: a propensity-score adjusted retrospective cohort study

PURPOSE

Although guidelines recommend adjunctive rifampin and gentamicin use for patients with staphylococcal prosthetic valve endocarditis (PVE), evidence behind the recommendation is limited and conflicting.

METHODS

We performed a retrospective cohort study of all patients with staphylococcal PVE within the Veterans Health Administration during 2003-2021. Patients were identified with diagnostic codes for prosthetic valves and positive blood cultures for Staphylococcus species and confirmed via manual chart reviews. The primary outcome was the composite of all-cause mortality or recurrence of staphylococcal PVE within one year from diagnosis. Inverse probability of treatment weighting (IPTW) was used to estimate the probability of individuals receiving rifampin using propensity scores. IPTW-adjusted multivariable Cox regression analysis was used to compare outcomes between patients who received rifampin and gentamicin, and those did not.

RESULTS

Among 373 patients with staphylococcal PVE, 275 (73.7%) and 225 (60.3%) received at least one dose of rifampin and gentamicin, respectively. The incidence of staphylococcal PVE increased from 0.47 (2003-11) to 0.77 (2012-21) per 10,000 hospitalizations. Gentamicin use declined over time (70.1% in 2003-2011 to 54.8% in 2012-2021, p = 0.04) while rifampin use did not change significantly (76.1% in 2003-2011 to 72.4% in 2012-2021, p = 0.43). The composite outcome was observed in 209 (56.0%). Neither rifampin use (adjusted hazard ratio [HR] 0.77, 95% CI 0.48-1.24) and gentamicin use (adjusted HR 1.11, 95% CI 0.71-1.74) was associated with the composite outcome.

CONCLUSION

No significant association was observed between adjunctive rifampin or gentamicin use and improved outcomes.

Molecular Biological Methods in The Etiological Diagnostics of Infective Endocarditis

Aim      To study the role of early blood tests using the polymerase chain reaction (PCR) (before or at initial stages of antibacterial therapy, within the first 24-48 hours after diagnosis) for the diagnosis of infective endocarditis (IE) and improvement of the etiological algorithm.Material and methods  The study included 154 patients with confirmed IE (DUKE, 2015) who underwent standard microbiological (culture) blood tests with a simultaneous molecular biological test (PCR study/sequencing) on the same type of biological material at the stage of primary diagnosis.Results In 117 (76.0%) examined patients, the etiologic agent was determined in blood samples by any of the methods used. Concordant results were obtained in 43 (36.8%) patients and discordant in 4 (3.4%) patients. In 29 (24.8%) patients, the causative agent of IE was determined only by the microbiological (cultural) examination of blood samples, and in 25 (21.4%) patients, only by the PCR study, including 3 cases of Bartonella spр. 23 patients had results of the microbiological (culture) blood tests that required clarification (70% CoNS, 26% gram-negative bacteria, one case of Enterococcus faecalis); 16 (69.6%) of 23 were not confirmed by the molecular biological method and were interpreted as contamination. In 1/3 of patients, the PCR blood study allowed increasing the accuracy of determining the causative agent of IE. Based on the integrated approach to the etiological diagnosis of IE, criteria for determining the causative pathogen were developed. This allowed reclassifying 9 (5.9%) diagnoses into the category of confirmed IE and to de-escalate the antibacterial therapy in every third examined patient. The microbiological and PCR studies of blood demonstrated comparable indexes of sensitivity, specificity and diagnostic accuracy [79.0, 86.0, 81.0% and 67.0, 93.0, 74.0%, respectively]. The PCR study of blood at the early stages of IE diagnosis (before or during the initial antibacterial therapy, within the first 24-48 hours after the IE diagnosis) is proposed as a control for Streptococcus spp., Staphylococcus aureus, CoNS, Enterococcus spр., and at the later stages of laboratory examination, especially in IE with an unspecified pathogen, as a priority method.Conclusion      The PCR study of blood samples is a highly informative method for the etiological diagnosis of IE that allows increasing the accuracy of the pathogen identification in every third patient and, thus, prescribing an effective antibacterial therapy.

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.

A New Benchmark for Modern Management of Valvular Heart Disease: The Whole-Life Cycle Management System

Valvular heart disease (VHD) is rapidly increasing in prevalence worldwide, affecting millions and significantly impacting global health care systems. Despite notable advancements in understanding VHD progression, perioperative management, imaging techniques, and transcatheter therapies over the past 2 decades, the condition has not received the attention it deserves from the public and policymakers. Many patients with VHD in low- and middle-income countries continue to experience low detection, intervention, and follow-up rates. Systematic care for elderly patients and those with severe comorbidities, as well as postoperative patients, remains insufficient, leading to higher mortality and morbidity rates. This review focuses on the deficiencies in VHD treatment within the Chinese health care system and discusses the modern management program, known as the whole-life cycle management system, that has been implemented to enhance the survival prognosis of VHD patients.

Infective endocarditis in octogenarians-a multicenter analysis†

OBJECTIVES

In an older population, infective endocarditis (IE) tends to present uniquely. In this study, we investigate the clinical presentation, microbiological profile and outcomes of IE in octogenarians.

METHODS

This multicentre retrospective analysis includes 4917 consecutive patients suffering from IE. We analysed the data on octogenarians undergoing surgery due to IE. Primary outcomes were 30-day mortality and 5-year survival.

RESULTS

We found 4625 (94.1%) were younger than 80 years old, whereas 292 patients (5.9%) were octogenarians. The median age of the non-octogenarian cohort was 65 years (54-73 years), whereas the median age of the octogenarian cohort was 82 years (81-84 years). The median EuroSCORE II was 16.5 (9.5-40.4) in the octogenarian group and 9.7 (4.4-21.5) in the non-octogenarian group (P < 0.001). There was a higher number of males in the non-octogenarian group (P < 0.001). Prosthetic valve endocarditis (P < 0.001) and pacemaker endocarditis (P < 0.001) were higher in the octogenarian group. Streptococcal infections were more frequent in octogenarians (P = 0.033), whereas a significantly higher number of non-octogenarians suffered from blood culture negative IE (P = 0.002).The rate of postoperative adverse cerebrovascular events and postoperative morbidities was comparable between the groups. The 30-day mortality was higher in the octogenarian group (P < 0.001). Survival rates at 1 and 5 years were 48% and 39%, respectively, in the octogenarian group (P < 0.001).

CONCLUSIONS

IE in the elderly is associated with a higher risk and may present with a different clinical profile. Although advanced age does play a role in the outcomes of surgery for IE, it alone should not be the sole factor to rule out surgery in this cohort.

A rare case of Aerococcus urinae native valve endocarditis

Background. Aerococcus urinae was initially considered a commensal of the urinary tract, but there is now increasing evidence for its involvement in urinary tract and systemic infections. A. urinae endocarditis has a non-negligible mortality rate and occurs mainly in patients with underlying conditions or the presence of extraneous material. Case presentation. This report handles the case of a 65-year-old male with cardiac antecedents, who was admitted to the cardiology department after a syncope of unknown origin and diagnosed with severe mixed aortic valve disease and mitral valve sclerosis through the means of transoesophageal echocardiography (TEE). During hospitalization, the patient progressively deteriorated with the development of shortness of breath and an inflammatory syndrome. Both the urine and blood cultures showed growth of A. urinae. Treatment with piperacillin/tazobactam was started empirically. Repeated TEE showed evidence of endocarditis with vegetation and perforation of the mitral valve that required an emergency surgery with mitral valve repair. After surgery, gentamicin and penicillin G were administered for 48 h, followed by combined ceftriaxone/penicillin G treatment for 6 weeks. At first, flucloxacillin was also associated as the culture of the valve was negative. Finally, the 16S rRNA gene PCR on the valve tissue confirmed the A. urinae endocarditis. Conclusion. A. urinae is an underestimated cause of serious infections such as endocarditis. Urinary tract infections mainly in older men can be an entry point for this type of invasive infection.

Transthoracic Echocardiography in Assessing Patients with Suspected Infective Endocarditis (TEASE): An Exploratory Study

Background: An extensive use of transesophageal echocardiography (TEE) has recently been suggested for the diagnosis of infective endocarditis (IE). In this study, we investigated whether among patients with negative transthoracic echocardiography (TTE), subgroups can be identified among whom TEE can be avoided/delayed. Methods: We conducted a retrospective study of 637 consecutive patients who underwent TEE for suspected IE. We selected 375 patients with negative TTE. For each patient, we obtained age, sex, blood culture (BC), blood exams, evidence of embolism, presence of moderate/severe heart valve disease, valve prostheses, and intracardiac devices. Results: IE was eventually diagnosed in 56 patients. Variables independently associated with IE at multivariate analysis included positive BC (OR 3.45; p = 0.006), evidence of embolism (OR 13.0; p < 0.001), bioprosthetic heart valves (OR 4.31; p < 0.001) and platelet count < 150,000/mL (OR 2.47; p = 0.014). In patients without any of these predictors for IE (n = 81), only 1 had a diagnosis of IE and no in-hospital IE-related deaths occurred. Among patients with negative BC (n = 127), IE prevalence increased with the number of other predictors, but IE-related mortality was 0%. IE prevalence (10.8%) and IE related in-hospital mortality (2.7%) were also rather low in patients with a positive blood culture without any other independent predictors for IE but were 20% (IE-related mortality 3.8%) and 71% (IE-related mortality 28.6%) in those with only one or 2-3 other IE predictors, respectively. Conclusions: Our data suggest that, among patients with suspected IE and negative TTE, subgroups can be identified in whom TEE might be safely avoided or delayed.

Infective Endocarditis of the TAVI Prosthesis: Emerging New Challenges

A 74-year-old patient presented to the emergency department with aggravating asthenia and persistent fever over the course of the last 2 weeks. He benefited 3 years prior from a self-expandable transcatheter aortic valve implantation (TAVI) for symptomatic severe aortic valve stenosis, as he refused open heart surgery. The blood workup showed leukocytosis and high C-reactive protein levels. However, the microbiological analysis remained negative. During his hospital stay, a transesophageal echocardiogram was performed, which showed thickening of the transcatheter heart valve leaflets and a vegetation of almost 2 cm attached to the stent of the TAVI. A high suspicion of endocarditis was established at this stage even in the absence of microbiological documentation. Surgery showed extensive damage to the prosthesis and consisted of the careful disengagement of the TAVI followed by a successful aortic valve replacement. The microbiological analysis of the excised TAVI identified Streptococcus bovis as the culprit bacteria. The patient fully recovered at the 1-year follow-up. TAVI endocarditis is a source of emerging new challenges, as they are becoming more frequent due to the increase in TAVI procedures, can affect the leaflets and the stent, and can present destructive evolution even with less aggressive bacteria, while remaining amenable to surgical treatment.

Four Faces of Infective Endocarditis: Where Thinking Outside the Box Was Crucial

Background/Objectives: Infective Endocarditis (IE) presents both a challenging diagnostic and treatment task. Methods: The incidence of IE has grown with the advancement in treatment technologies offered to patients, including intra-cardiac electrical device insertion and a variety of transcutaneous structural interventions. Results: Guidelines recommend the involvement of a multi-disciplinary approach to prompt diagnosis and decisions regarding treatment. Conclusions: We present the management conundrums of four complex cases of IE and highlight the importance of the Extended Endocarditis Team.

New insights into iron uptake in Streptococcus mutans: evidence for a role of siderophore-like molecules

Streptococcus mutans, a gram-positive coccus commonly found in the human oral cavity, is the primary causative agent of dental caries as well as infective endocarditis. Bacteria produce potent iron chelators called siderophores to absorb iron. Because, there are few studies on siderophore-mediated iron transport in S. mutans, the current study investigates the presence of such a mechanism in S. mutans GS-5. Deferration of culture medium and different concentrations of 2, 2'-Bipyridyl has been used to simulate iron-restricted conditions. Iron restriction alters the colony morphology and slows bacterial growth. Cross-feeding conditioned medium into an iron-restricted medium promotes bacterial growth, indicating the presence of siderophore-like molecules. This was further confirmed by Chrome Azurol S (CAS) assay and Modified CAS-agar assay. Cśaky's and Arnow's assays detected the presence of hydroxamate and catecholate-type molecules in optimal and iron-restricted conditions, respectively. Further, the siderophore-like molecules were extracted and purified with thin layer chromatography (TLC). TLC elutes were also found to be positive for iron-chelation in CAS-agar assay and aided growth of S. mutans under iron-restricted conditions. LC-MS analysis of culture supernatants under iron-restricted conditions identified iron-binding small molecules, including a catechol structural motif. Computational analysis utilizing KEGG and BLASTp suggested homologues of siderophore biosynthesis and transport proteins, including genes associated with mutanobactin production. These findings indicate a possible siderophore-mediated iron uptake mechanism in S. mutans GS-5, warranting further molecular studies and advanced spectroscopic characterization of this unidentified siderophore. Once confirmed, this mechanism can be used as a potential drug target to control streptococcal infection.

Exploring sex differences in infective endocarditis - a prospective, observational study from Western Norway

BACKGROUND

We aimed to investigate sex-differences among patients with infective endocarditis (IE) in Western Norway, focusing on clinical presentation, treatment strategies, and outcomes.

METHODS

This prospective observational study included 131 females, and 366 males diagnosed with IE between 2016 and 2022. Clinical and microbiological characteristics were analysed using chi-squared or Fisher's exact tests, while survival data were assessed via Kaplan-Meier estimates and multiple Cox regression models.

RESULTS

The mean age was 69 years for females and 66 years for males (p = 0.317).

PRIMARY OUTCOMES

Mortality rates were significantly higher in females at 30 days (13% vs. 7%, p = 0.028), at 90 days (19% vs. 11%, p = 0.016), and overall (46% vs. 36%, p = 0.016), with a mean follow-up of 3.2 years (± 2.3 years).

SECONDARY OUTCOMES

The mitral valve was more frequently affected in females than in males (31% vs. 17%, p < 0.001), and Staphylococcus aureus more often the microbial cause (36% vs. 27%, p = 0.049). While surgical treatment rates were similar (26% of females and 34% of males, p = 0.075), females with aortic valve IE underwent surgery at a significantly lower rate (23% vs. 39%, p = 0.001) and experienced longer delays before surgery (median 25 vs. 21 days, p = 0.043). Multivariable analysis identified higher age (HR 1.02, 95% CI 1.00-1.04, p = 0.014) and mitral valve infection (HR 2.88, 95% CI 1.57-5.29, p < 0.001) as independent predictors of 90-day mortality, while surgery significantly improved survival (HR 0.38, 95% CI 0.17-0.81, p = 0.013).

CONCLUSIONS

Mitral valve IE was more common in females and strongly associated with higher mortality. Females with IE had higher mortality rates, more frequent mitral valve involvement, and a greater incidence of S. aureus infections. Despite the clear survival benefit of surgery, females with aortic valve IE underwent fewer and later surgeries. These findings highlight potential sex disparities in IE management and emphasize the need for further research into sex-based differences in treatment strategies and outcomes.

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.

From Heart to Eye: Central Retinal Artery Occlusion Secondary to Endocarditis: Septic Embolism

Infective endocarditis (IE) remains a medical challenge. Potential complications such as heart failure and septic embolization may arise, prompting early recognition and treatment. We present the case of a 78-year-old woman with sudden, painless monocular vision loss in the left eye, without other accompanying symptoms. Ophthalmologic evaluation revealed central retinal artery occlusion. A holosystolic murmur was heard at the apex. Further echocardiography confirmed IE. Despite efforts, prognosis of IE is poor, with an in-hospital mortality of 25% in our country, with high risk of embolism (20% to 50%). According to epidemiology, central retinal artery occlusion is a rare complication, resulting from valvular vegetation, occurring in <1% of patients. Unfortunately, there is no accepted treatment to reverse retinal damage caused by central retinal artery occlusion.

Mitral Valve Aspergillus Endocarditis With Aortal Embolization in an Immunocompetent Patient

Aspergillus endocarditis is a rare condition. The clinical presentation is often atypical and insidious, resulting in delayed diagnosis and challenges in management. We report a case of native mitral valve Aspergillus endocarditis in an immunocompetent patient, with rare aortal embolization, who was managed in a multidisciplinary approach. Evidence for Aspergillus endocarditis is limited, and prospective data are unlikely to be available because of the low incidence of the disease. This case report adds great value to the current published case series to provide experience for clinicians when tackling similar conditions. Aspergillus endocarditis is rare but fatal. Cardiac surgery improves early survival, but long-term outcomes remain dismal. An endocarditis team with a multimodality approach is paramount to manage this difficult-to-treat disease.