2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM)

Patient characteristics, presentation, causal microorganisms, and overall mortality in the NatIonal Danish endocarditis stUdieS (NIDUS) registry

BACKGROUND

Most knowledge on infective endocarditis (IE) comes from large IE cohorts that include patients from tertiary hospitals, leading to referral bias and retrospective population-based studies. This highlights the need for a more detailed characterization of IE in unselected patient cohorts.

METHODS

In the National Danish Endocarditis Studies (NIDUS) registry, all hospitalizations in Denmark from 2016 to 2021 with an IE diagnosis were reviewed and validated using electronic medical records (EMR) by healthcare professionals under the supervision of IE experts. Episodes meeting the European Society of Cardiology 2015 modified diagnostic criteria for possible or definite IE were included.

RESULTS

We screened 4390 unique patients, of whom 3557 (81%) were included in the NIDUS registry. Of the 3557 unique patients, 2832 (79.6%) were classified as definite IE and 725 (20.4%) as possible IE. The age was 73.7 years, and most patients were men (68.3%). In total, 689 (19.4%) underwent surgery during hospitalization. The most frequent comorbidities were diabetes (23.7%), heart failure (18.7%), and chronic kidney disease (17.4%). Most patients presented with fever (61.1%), followed by dyspnea (33.0%) and myalgias (27.0%). Sepsis was found in 828 (23.3%) patients, while 378 (10.6%) had signs of embolization at admission. Positive blood cultures were identified in 3191 (89.7%) patients, and the most frequent microbiological etiology was Staphylococcus aureus (31.9%). The in-hospital mortality was 17.3%, and the 1-year mortality rate was 31.3%.

CONCLUSION

The NatIonal Danish endocarditis studies (NIDUS) registry provides comprehensive, granular, and nationwide data on a cohort of patients with infective endocarditis, revealing that when selection is not restricted to tertiary hospitals or voluntary registries, some important differences emerge. Patients with IE are on average older, have a similar burden of comorbidities, and less often undergo surgery. Minimizing selection bias with the use of a national registry provides a clearer picture of IE as it occurs in real-world clinical settings.

Epidemiological Profile and Mortality of Infective Endocarditis Over the Past Decade: A Systematic Review and Meta-Analysis of 133 Studies

Infective endocarditis (IE) is an increasingly prevalent condition with relatively high mortality, whose epidemiology has become more complex with an aging population, an increased number of comorbidities, and an increasing incidence of health-care associated IE. Epidemiological data on the causative microorganisms of IE, prevalence of involvement of the different cardiac valves, and IE-associated mortality are clinically relevant. Eligible studies were identified through a systematic search of PubMed/MEDLINE database from 2010 to 2020, and a random effects model meta-analysis was conducted. 133 studies comprising 132,584 patients from six continents were included in this systematic review. The most common causative agents were Staphylococci species in 36% of cases, followed by Streptococci species (26%) and Enterococci species (10%). Out of studies that provided further speciation, the predominant species was Staphylococcus aureus with an incidence of 29%, followed by Viridans group Streptococcus (12%). The short-term mortality rate (defined as in-hospital or 30-day mortality) was 17%. The highest mortality was reported in studies from Latin America with a mean mortality rate of 33% and the lowest mortality was reported in studies from Oceania at 13%. The aortic valve was the most commonly affected valve (46%), followed closely by the mitral valve (43%). The prevalence of tricuspid valve IE was 7% and multivalvular IE occurred in 14% of cases. Our study highlights a shift in epidemiological profile of IE over the last decade with S. aureus identified as the most common causative microorganism of IE. PROTOCOL REGISTRATION: PROSPERO CRD42024602342.

Infective endocarditis caused by Gemella - a retrospective registry-based study

PURPOSE

Infective endocarditis (IE) is diagnosed using the Duke criteria, which were updated in 2023. In the Duke-ISCVID 2023 criteria, Gemella was recognised as a typical IE pathogen. This study investigates the impact of this change and compares the clinical characteristics of Gemella IE to IE caused by other pathogens.

METHODS

Data on IE caused by Gemella species and other pathogens was retrieved from the Swedish Registry of Infective Endocarditis (SRIE). Clinical characteristics of Gemella IE were compared to episodes of IE caused by non-beta haemolytic streptococci, by Staphylococcus aureus and by enterococci.

RESULTS

In the SRIE, 29 episodes of Gemella IE were identified among a total of 7677 registered episodes, corresponding to 0.4% of all cases. The most common species were Gemella morbillorum (47%) and Gemella bergerii (27%). The proportion of episodes meeting the criteria for definite IE increased from 13 (45%) with the modified Duke criteria to 21 (72%) with the Duke-ISCVID criteria. Median age of patients with Gemella IE was 70 years, 40% were females and 90% hade native valve IE. One third of the patients underwent heart valve surgery and only one patient (3%) died. Many clinical aspects of IE caused by Gemella resembled those of IE caused by non-beta haemolytic streptococci.

CONCLUSIONS

Gemella IE is a rare condition and shares several characteristics with IE caused by non-beta haemolytic streptococci. The prognosis of IE caused by Gemella appears to be relatively favourable.

Urgent mitral valve replacement after mechanical thrombectomy for ischemic stroke

Mitral valve replacement, or any major cardiac surgery, is usually delayed for a minimum of 6 weeks after a previous stroke, mainly to avoid recurrence, if not associated with infective endocarditis or aortic dissection. A 50-year-old lady, diagnosed with severe mitral stenosis with a large left atrial clot, had a sudden onset cerebrovascular accident (CVA) while awaiting surgery. Mechanical thrombectomy (MT) of large vessel M1 middle cerebral artery (MCA) occlusion was done, and after adequate neurological improvement, she was taken up for emergency mitral valve replacement within 12 h, because of hemodynamic instability leading to low cardiac output syndrome and to avoid the chance of future CVA due to large clot burden. A 23-mm mechanical mitral valve prosthesis was implanted, and the postoperative course was uneventful. She was discharged on the fifth postoperative day, with stable hemodynamics and no residual neurological deficit. She was asymptomatic with normal echocardiographic findings on 12 months' follow-up. Major cardiac surgery after MT for ischemic CVA may be a viable option, if indicated, provided post-MT neurological improvement is adequate.

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

AngioVac-assisted management of histoplasma capsulatum endocarditis in a bioprosthetic aortic valve: challenges and outcomes

BACKGROUND

Histoplasma capsulatum infective endocarditis (IE) is rare and often fatal, especially in prosthetic valve patients, due to delayed diagnosis and limited therapeutic options. This case demonstrates the utility of AngioVac for managing large fungal vegetations, underscores the importance of considering fungal IE in culture-negative cases, and highlights the role of a multidisciplinary approach in high-risk patients. We report a 76-year-old female with a bioprosthetic aortic valve who presented with persistent culture-negative fever, splenic infarcts, and large vegetations on her prosthetic valve. Extensive diagnostic workup confirmed fungal endocarditis after AngioVac-assisted debulking revealed H. capsulatum on tissue cultures. Despite prompt initiation of antifungal therapy and multidisciplinary management, her course was complicated by recurrent embolic events, septic shock, and eventual death.

CONCLUSION

This case underscores the importance of considering fungal IE in culture-negative cases, especially in high-risk patients such as those with prosthetic valves. It also highlights the role of advanced diagnostic techniques and minimally invasive interventions like AngioVac in managing complex cases, despite their limitations.

Egyptian experience with aortic valve repair using Ozaki procedure in adult and pediatric patients

BACKGROUND AND AIM

to document the Egyptian experience with Ozaki procedure in adults and children and compare the clinical outcomes of the procedure to that of aortic valve replacement (AVRc) in adult patients.

PATIENTS AND METHODS

The study included adult and pediatric patients submitted to the Ozaki procedure with available 1-year follow up data. In addition, adult patients submitted to AVRc during the study period were also included for comparison. Recorded outcome parameters included intensive care unit stay, hospital stay and early and late postoperative complications and mortality.

RESULTS

The present prospective study included 72 adult and 25 pediatric patients with aortic valve disease (AVD). Adult patients were submitted to Ozaki procedure (n = 31) or AVRc (n = 41) while all pediatric patients were submitted to Ozaki procedure. One year follow up demonstrated that patients submitted to the Ozaki procedure had significantly higher peak pressure gradient (28.6 ± 7.6 versus 21.0 ± 5.7 mmHg, p < 0.001) and higher mean pressure gradient (13.5 ± 4.4 versus 10.5 ± 3.2 mmHg, p = 0.002) when compared to patients in the AVRc group. In the Ozaki group, moderate aortic stenosis (AS) was identified in only 1 patient. In the pediatric group, at one year follow up, there were 8 patients (32.0%) with trivial aortic regurgitation (AR), 12 patients (48.0%) with mild AR and 4 patients (16.0%) with moderate AS.

CONCLUSIONS

Ozaki procedure appears to be a promising alternative to AVRc in adults and children with AVD with good efficacy and safety profile.

A colorimetric sandwich assay based on magnetic separation of Brevinin-1BW-functionalized magnetic beads and porcine IgG for the detection of Staphylococcus aureus

A novel strategy integrating Brevinin-1BW (BW)-functionalized magnetic bead-based separation with a colorimetric immunoassay was developed to concentrate and enrich Staphylococcus aureus (S. aureus) from sample matrices using magnetic beads functionalized with antimicrobial peptide BW (MBs-BW) as carriers. To ensure the selectivity of the method, horseradish peroxidase (HRP)-labeled porcine IgG (HRP-porcine IgG) was used as a molecular recognition reagent and signal amplification probe. MBs-BW/S. aureus/HRP-porcine IgG probe sandwich complex was successfully obtained. HRP chromogenic substrate 3,3',5,5'-tetramethylbenzidine (TMB) was used to realize the chromogenic reaction. Finally, S. aureus was quantitatively analyzed based on the color signal generated. Under the optimal conditions, the assay showed a response in the concentration range of 1.0 × 102-1.0 × 107 CFU/mL of S. aureus, and the detection limit was as low as 60 CFU/mL. This method does not require complicated sample pretreatment, and the operation process is fast and simple, which can directly complete the whole process of bacterial enrichment and detection. The recovery of this strategy in different types of spiked samples reached 86.8-97.8%, and the analytical results of this strategy were highly consistent with those of the conventional plate counting method. This strategy provides a new way for the rapid detection of S. aureus in complex samples.

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.

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.

Can ChatGPT answer patients' questions about nuclear stress tests and 18F-Flurodeoxyglucose PET for myocardial inflammation?

BACKGROUND

Several modalities are used for stress testing and require specific patient preparation. 18F-Flurodeoxyglucose positron emission tomography (FDG PET) is an important tool in the diagnosis and risk stratification of patients suspected of cardiac sarcoidosis and endocarditis [1-3]. There is a need for improved patient access to questions regarding cardiac testing to ensure proper adherence to instructions. We sought to evaluate the effectiveness of ChatGPT in answering questions about stress testing and cardiac FDG PET inflammation scans.

METHODS AND RESULTS

We generated fifty-eight questions about stress testing and cardiac FDG PET inflammation scans. OpenAI ChatGPT-3.5 and -4o were used to answer the questions. The answers were graded by three nuclear cardiologists as the following categories: 1 = correct and complete, 2 = somewhat correct/somewhat complete, 3 = incorrect: no benefit, or 4 = incorrect: harmful/misleading information (Table I). Of the 174 grades assigned to responses to the questions from ChatGPT-3.5, 62/174 (36%) were correct and complete, 93/174 (53%) were somewhat correct/somewhat complete, 12/174 (7%) were incorrect: no benefit, 7/174 (4%) were incorrect: harmful/misleading information. Of the grades assigned to responses to questions from ChatGPT-4o, 107/174 (61%) were correct and complete, 62/174 (36%) were somewhat correct/somewhat complete, 3/174 (2%) were incorrect: no benefit, and 2/174 (1%) were incorrect: harmful/misleading information.

CONCLUSIONS

ChatGPT can provide some accurate responses to patient questions regarding stress tests and cardiac FDG PET inflammation studies, and its accuracy has improved over time; however, it is not suitable as a primary resource for clinical care at this stage of development.

Usefulness of a hub and spoke TDM-guided expert clinical pharmacological advice program of dalbavancin for optimizing very long-term curative or suppressive treatment of chronic staphylococcal infections

A hub and spoke model for optimizing long-term treatment of chronic staphylococcal infections with dalbavancin based on therapeutic drug monitoring (TDM)-guided expert clinical pharmacological advice (ECPA) was implemented. This multicentric retrospective cohort study included patients receiving dalbavancin monotherapy lasting >6 weeks at different spoke hospitals having treatment optimized by means of a TDM-guided ECPA program at a hub hospital. Optimal pharmacokinetic/pharmacodynamic target against staphylococci with an MIC up to 0.125 mg/L was defined as dalbavancin concentrations >8.04 mg/L. Patients received dalbavancin therapy for curative (curative group) or suppressive (suppressive group) purposes. Clinical outcome was assessed by means of repeated ambulatory visits. A total of 12 spoke hospitals applied for 414 TDM-based ECPA for 101 patients, of whom 64.4% (65/101) were treated for curative and 35.6% (36/101) were for suppressive purposes. In the curative and suppressive groups, TDM-based ECPA optimized treatment for up to 14 and 28 months, respectively, and ensured median optimal exposure of 95.7% and 100%, respectively. In the curative group, having <70% of treatment time with concentrations above the optimal target increased failure risk [odds ratio (OR), 6.71; confidence interval (CI), 0.97-43.3; P = 0.05]. In the suppressive group, infective endocarditis was associated with an increased risk of ineffective treatment (OR, 8.65; CI, 1.29-57.62; P = 0.046). Mild adverse events were reported in 4.5% (5/101) of cases. A hub and spoke TDM-guided ECPA program of dalbavancin may be cost-effective for optimizing long-term treatment of chronic staphylococcal infections and for patients admitted to hospitals lacking in-house MD clinical pharmacologists.

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.

Lethal Case of Microbacterium paraoxydans Bloodstream Infection Associated with Mitral Endocarditis in Human: A Case Report, analyses of the 16S rDNA sequences and review of the literature

INTRODUCTION

Microbacterium species are gram-positive, non-fermentative, yellow-pigmented rods commonly found in animals and various environmental sources. Herein is reported the first case of a fatal bloodstream infection associated with mitral endocarditis caused by Microbacterium paraoxydans in a human patient.

METHODS

A 64-year-old man without significant infectious risk factors, except for rheumatoid spondylarthritis treatment, developed severe chest pain, paralysis of the left leg, respiratory distress, and high fever. Diagnostic investigations revealed ischemic stroke and mitral insufficiency. Despite valve replacement surgery and antibiotic treatment, the patient's condition deteriorated, resulting in valve disinsertion, pneumopathy, and death.

RESULTS

Blood cultures taken later confirmed the presence of Microbacterium sp., identified as M. paraoxydans by 16S rDNA gene sequencing.

CONCLUSION

This case highlights the importance of using sequencing for accurate identification of Microbacterium species. This report emphasizes the need for research and surveillance to understand the clinical characteristics, treatment strategies, and impact of Microbacterium infections in humans.

Urgent and emergent pediatric cardiovascular imaging

The need for urgent or emergent cardiovascular imaging in children is rare when compared to adults. Patients may present from the neonatal period up to adolescence, and may require imaging for both traumatic and non-traumatic causes. In children, coronary pathology is rarely the cause of an emergency unlike in adults where it is the main cause. Radiology, including chest radiography and computed tomography in conjunction with echocardiography, often plays the most important role in the acute management of these patients. Magnetic resonance imaging can occasionally be useful and may be suitable in more subacute cases. Radiologists' knowledge of how to manage and interpret these acute conditions including knowing which imaging technique to use is fundamental to appropriate care. In this review, we will concentrate on the most common cardiovascular emergencies in the thoracic region, including thoracic traumatic and non-traumatic emergencies and pulmonary vascular emergencies, as well as acute clinical disorders as a consequence of primary and postoperative congenital heart disease. This review will cover situations where cardiovascular imaging may be acutely needed, and not strictly emergencies only. Imaging recommendations will be discussed according to the different clinical presentations and underlying pathology.

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.

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.

Association between weight changes and infective endocarditis in patients with diabetes: A nationwide population-based cohort study

BACKGROUNDS

The association between weight change in patients with diabetes, and the development of infective endocarditis (IE) has never been studied. Therefore, we evaluated the associations of weight changes in patients with diabetes with the development of IE.

METHODS

In this Korean population-based cohort study, we included patients with diabetes aged ≥20 years who underwent health screenings twice in a 2-year interval between 2009 and 2012. Patients were categorized into five groups according to the degree of weight change between the two health screenings and were followed up until December 2018. A patient with a weight change of ≤-10% was designated to the severe weight loss group, -10 to ≤-5% to the moderate weight loss group, -5 to ≤5% to the stable weight group, 5 to ≤10% to the moderate weight gain group, and ≥10% to the severe weight gain group. The primary outcome was the incidence of IE.

RESULTS

A total of 1,762,108 patients with diabetes were included. There were 67,580 (3.9%) individuals with severe weight loss, 247,969 (14.1%) with moderate weight loss, 1,267,849 (72.0%) with stable weight, 135,774 (7.7%) with moderate weight gain, 42,936 (2.4%) with severe weight gain. During the follow-up (median, 5.21 years), 828 cases of IE occurred. After adjusting for covariates, both weight loss (HR: 2.41, 95% CI: 1.87-3.12 for the severe weight loss group; HR: 1.28, 95% CI: 1.05-1.55 for the moderate weight loss group) and weight gain (HR: 1.17, 95% CI: 0.91-1.50 for the moderate weight gain group; HR: 1.59, 95% CI: 1.11-2.28 for the severe weight gain group) were associated with an increased risk of IE compared to those for the stable weight group.

CONCLUSION

Both weight gain and weight loss are associated with an increased incidence of IE, and the greater the degree of weight change, the greater the risk.

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.

Reoperative surgery for early- and late-onset prosthetic valve endocarditis: temporal trends and outcomes

OBJECTIVES

Prosthetic valve endocarditis (PVE) remains a serious complication following aortic valve replacement, with varying outcomes based on timing of presentation. This study investigated the relationship between timing of reoperation and outcomes in PVE patients using a nationwide database, while examining temporal trends and identifying mortality risk factors.

METHODS

We analysed 406 patients who underwent reoperative surgery for PVE between 1996 and 2019 across the United Kingdom using the National Institute of Cardiovascular Outcomes Research database. Patients were categorized into early (≤1 year, n = 131) and late (>1 year, n = 275) reoperation groups. Propensity score matching was performed to compare outcomes, and multivariable analysis identified mortality predictors.

RESULTS

The overall incidence of reoperative surgery for PVE increased over the study period, while the proportion of early-onset PVE decreased from 85.7% in 1998 to 20% in 2019. In matched groups (113 pairs), early reoperation cases required longer cardiopulmonary bypass (135 vs 122 min, P = 0.005) and cross-clamp times (95 vs 88 min, P = 0.011), with extended hospital stays (18.5 vs 14.0 days, P = 0.006). Overall mortality was 8.4%, with an early mortality of 10.8% opposed to 6.2% in late cases (P = 0.338; Lasso AUC: 0.746). Age emerged as the strongest predictor of mortality (OR: 1.14, 95% CI: 1.05-1.27, P = 0.0).

CONCLUSIONS

This nationwide analysis demonstrates improved PVE outcomes compared to historical data, with overall mortality of 8.4%. While early reoperations were associated with more complex procedures and longer hospital stays, mortality rates were statistically similar. Age remains the primary determinant of mortality risk.

Common Bacterial Infections in Persons Who Inject Drugs

Opioid use in the United States has increased dramatically. Bacterial infections are common among persons who inject drugs (PWID), and there is a disparity in the care these individuals receive. As such, outcomes associated with these infections can be poor. Healthcare providers can address these disparities through optimal pharmacotherapy recommendations and assistance with changing approaches to the management of PWID.

Clinical profile and outcomes among patients with cardiac implantable electronic device presenting as isolated pocket infection, pocket-related infective endocarditis, or lead-related infective endocarditis

AIMS

The clinical spectrum of cardiac implantable electronic device (CIED) infections includes isolated pocket infection (IPI), pocket infection complicated by infective endocarditis (PIRIE), and lead-related infective endocarditis (LRIE). The aim of this study was to assess the risk factors, clinical course, and outcomes in patients with CIED infections and to demonstrate differences between PIRIE and LRIE.

METHODS AND RESULTS

The retrospective analysis of data from 3847 patients undergoing transvenous lead extraction for non-infectious (2640; 68.62%) and infectious (1207; 31.38%) indications, including 361 (29.91%) IPI, 472 (39.11%) PIRIE, and 374 (30.99%) LRIE, showed some differences in risk factors, clinical course, and outcomes between the subgroups. Unlike PIRIE, diabetes [hazard ratio (HR) = 1.488; 95% confidence interval (CI; 1.178-1.879), P < 0.001] and lead abrasion [HR = 2.117; 95% CI (1.665-2.691), P < 0.001] increased the risk of LRIE. The risk of pocket infection spread was greater with Staphylococcus aureus infection [HR = 1.596; 95% CI (1.202-2.120), P < 0.001]. Compared with LRIE, patients with PIRIE had lower levels of inflammatory markers and lower prevalence of vegetations. Mortality in PIRIE compared with LRIE patients was lower (53.18 vs. 62.30%; P < 0.001) and comparable to IPI (50.69%; P = 0.162) at long-term [median 1828 (815-3139) days] follow-up.

CONCLUSION

Cardiac implantable electronic device infections share common risk factors; however, diabetes and intra-cardiac lead abrasion predispose to LRIE, whereas multiple leads and S. aureus in pocket culture are risk factors for pocket infection spread. Compared with LRIE, the clinical course of PIRIE was milder, and short- and long-term mortalities were lower, but comparable with IPI after >1 year. This may be an argument in favour of categorization into primary LRIE and secondary endocarditis, i.e. PIRIE.

Investigation of the in vitro antimicrobial activity of eravacycline alone and in combination with various antibiotics against MDR Acinetobacter baumanni strains

BACKGROUND

Acinetobacter baumannii is an obligately aerobic, non-motile, non-fermenting, gram-negative, opportunistic pathogen. The fact that this pathogen, which is the leading cause of nosocomial infections, is naturally resistant to many antibiotics and quickly acquires new resistance mechanisms gradually limits the antibiotic options that can be used in treatment. So, our study aims to investigate the in vitro antibacterial effects of eravacycline, a new tetracycline-class antibiotic, and compare this antibiotic with the antibiotics used in the clinic to treat the infection caused by A. baumannii. Also, eravacycline was tested in combination with meropenem or colistin against A. baumannii strains, which are resistant to colistin and meropenem. The antibiotic susceptibility of strains was determined by the microbroth dilution method. In addition, the agar dilution method determined the mutant inhibition concentration (MPC) values of the studied antibiotics. To investigate the effects of the antibiotics mentioned in our study on biofilm formation, the biofilm-forming abilities of the strains were evaluated by the crystal violet staining method. The bactericidal and synergistic effects of the studied antibiotics alone or in combination were determined by the time-dependent killing curve (TKC) method.

RESULTS

The present antibacterial susceptibility experiments showed that 98% of the strains were multi-drug resistant (MDR). Our results in mutant inhibition studies showed that eravacycline is an antibiotic with the potential to prevent the emergence of resistant mutants with its low MPC value. When the effects of antibiotics on biofilm formation were investigated in our thesis study, it was determined that 95% of our strains formed biofilm. In biofilm inhibition experiments, it was observed that eravacycline at minimum inhibitory concentration (MIC) inhibited biofilm formation by 84% alone, 86% combined with colistin, and 85% combined with meropenem. Our combination experiments showed that 1×MIC eravacycline-meropenem and 4×MIC eravacycline-colistin combinations were synergistic against A. baumannii strains. In addition, the combination of 4×MIC eravacycline-meropenem also showed bactericidal activity at the 24th hour. No antagonist effects were detected in our combination studies.

CONCLUSION

Present results reveal essential pharmacodynamic data on eravacycline, a new antibiotic for treating A. baumannii infections, which poses a global threat.

CLINICAL TRIAL NUMBER

Not applicable.

The Association Between Cutaneous Wounds and Infective Endocarditis: A Nationwide Self-Controlled Case Series Study in Taiwan

BACKGROUND AND OBJECTIVES

We aim to investigate whether disruption of the skin defense in the form of cutaneous wounds may increase the incidence rate (IR) of infective endocarditis (IE) in the general population.

METHODS

We performed a retrospective population-based study using Taiwan's National Health Insurance Database from 2013 to 2022. Self-controlled case series (SCCS) was used to investigate the time-sequential association between cutaneous wounds and IE. Adult patients with both cutaneous wounds (exposure) and IE (outcome) in the database were included in the study. Conditional Poisson regression was used to calculate the adjusted IR ratios (aIRRs) of IE during the 4 weeks following wounds to that of the baseline period within the same individuals.

RESULTS

We enrolled 3,241 eligible patients for SCCS analysis. The risks of IE were elevated in the second week (aIRR, 2.16; 95% confidence interval [CI], 1.07-4.35; p value=0.032) after a treated traumatic wound. The risks of IE were elevated in the first (aIRR, 1.56; 95% CI, 1.17-2.09; p value=0.002) and second (aIRR, 1.58; 95% CI, 1.19-2.10; p value=0.002) after a treated non-traumatic wound.

CONCLUSIONS

Both traumatic and non-traumatic cutaneous wounds are associated with an increased risk of IE within the first 2 weeks after treatments among the general population in Taiwan. Clinicians should be vigilant for symptoms or signs associated with IE in these patients to avoid delays in diagnosis and treatment.

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.

Nuclear imaging studies in patients with an indeterminate diagnosis of infective endocarditis: A retrospective analysis of a case series

OBJECTIVES

To determine the role of nuclear imaging (NI) in evaluating inconclusive cases with suspicion of infective endocarditis (IE).

METHODS

Consecutive patients with an indeterminate diagnosis of IE who underwent labelled leucocyte scintigraphy (LS) or 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) between 2018 and 2021 at 2 reference hospitals in Rio de Janeiro were retrospectively analysed. Subsequent confirmed or rejected diagnoses of IE were evaluated, in addition to clinical and imaging data. Kappa coefficient was used to compared the diagnostic agreement between echocardiographic and NI findings, with a p-value <0.05 considered statistically significant.

RESULTS

A total of 85 NI scans (28 FDG-PET/CT, 57 LS) from 76 patients were evaluated, of whom 48 (63.2 %) underwent only LS, 19 (25 %) only FDG-PET/CT, and 9 (11.8 %) both studies. Average age was 63.8 years (SD ± 18.5) and 51.3 % were women. Prosthetic valves were present in 15.8 % of cases, and intracardiac devices in 10.5 %. Among the 76 patients, 18 (23.7 %) had NI findings suggestive of IE. A total of 28 patients (36.8 %) were ultimately diagnosed with IE, 28.6 % of whom had confirmed infections by NI scans. Echocardiographic results had a low level of agreement with NI findings in those diagnosed with IE (kappa = -0.44).

CONCLUSIONS

Nuclear imaging contributed to the diagnosis of IE in approximately 30 % of subsequently confirmed cases, which were initially classified as inconclusive by echocardiography. The low level of agreement between these methods underscores their complementary role in the diagnosis of IE, particularly in indeterminate cases.

Real-world evidence of dalbavancin effectiveness as consolidation therapy in infective endocarditis due to Enterococcus spp

Enterococcal endocarditis (EIE) affects elderly patients, with high rates of complications and mortality, and dalbavancin (DBV) exhibits significant antimicrobial activity against most enterococci. However, data are lacking on the use of DBV in EIE. The main objective was to evaluate the outcomes of treatment with DBV in the consolidation therapy of IE by Enterococcus spp.

METHODS

Spanish-French retrospective observational study of patients with EIE enrolled between November 2016 and June 30, 2022 receiving DBV in consolidation phase and followed for ≥12 months.

RESULTS

Ninety-eight patients were enrolled, 69.4 % male, with mean age of 71.2 (±12.51) years and median Charlson index of 5 (IQR 3-7). Criteria for definite IE were met by 84.7%; 60.2 % had IE on native valve, 26.5 % late prosthetic IE, 8.2 % early prosthetic IE, 2 % cardiovascular implantable electronic-IE (CIE-IE), and 3.1 % CIE-IE and valve. Aortic valve involvement was observed in 66.3 %. E. faecalis was isolated in 86.7 %, E. faecium in 11.2 %; 32.6 % underwent surgery, and these had a higher cure rate (100 % vs 75.8 %; p = 0.005) and lower mortality (0 vs 13.6 %; p = 0.029). DBV was administered to facilitate discharge in 88.8 %. Total dose was 2500 mg (1500-3000) over 3.5 weeks (2-4). Loss to follow-up was 0 %, relapse rate 8.2 %, 1-year IE-related mortality 3.1 %, and clinical cure rate 81.2 %. Severe adverse events affected 1 % (acute tubular necrosis). Hospital stay was reduced by 21 days (14-28).

CONCLUSIONS

DBV appears to be highly effective, safe, and cost-effective as consolidation therapy in patients with IE caused by Enterococcus spp., with minimal adverse events.

Epidemiological, clinical and microbiological aspects of infective endocarditis in Türkiye

PURPOSE

Infective endocarditis (IE) is a evolving disease with a shifting epidemiology and disease burden over time. This study aimed to compare the epidemiological and clinical aspects of IE over three time periods across eleven years.

METHODS

This was a retrospective cohort, multicenter study conducted in Türkiye, comparing three periods: 2013-2016, 2017-2020, and 2021-2023. Epidemiological and microbiological characteristics, as well as patient outcomes, were analyzed and compared across these periods.

RESULTS

A total of 1,044 patients diagnosed with IE were included. The median (Q1-Q3) age was 57 (44-68) years, with an increasing pattern (p < 0.001). Throughout the study period, the prevalence of intracardiac devices increased, whereas the prevalence of degenerative and congenital heart diseases declined. Among all patients, the most frequently identified pathogens were staphylococci (36.4%), followed by streptococci (14.0%) and enterococci (11.9%). Throughout the three periods, there was a significant increase in staphylococci, with S. aureus emerging as the predominant pathogen in all type IE. The in-hospital mortality rate among all patients was 22.5%. Independent risk factors for in-hospital mortality included ≥ 65 age(OR = 1.9), chronic kidney disease (OR = 1.9), nosocomial acquisition (OR = 2.1), Candida spp. infection (OR = 2.9), prosthetic valve IE (OR = 1.9), vegetation size > 15 mm (OR = 1.6), and central nervous system emboli (OR = 2).

CONCLUSION

The epidemiology of IE is undergoing significant changes, leading to shifts in microbiological profiles and clinical presentations. Effective management of IE should be guided by established clinical guidelines while integrating up-to-date epidemiological data to ensure comprehensive and evidence-based patient care.

Temporal trends, clinical characteristics and prognostic factors analysis of infective endocarditis: a multicenter ambispective cohort study in China

BACKGROUND

The epidemiological and clinical characteristics of infective endocarditis (IE) in mainland China, particularly following the COVID-19 pandemic, remain insufficiently understood. This study aims to examine temporal trends, clinical features, and factors influencing in-hospital mortality of IE in northern China from 2019 to 2023.

METHODS

This multicenter, retrospective study included 961 patients diagnosed with IE between 2019 and 2023 across hospitals in Henan, Shandong, and Tianjin. Data were collected on demographics, comorbidities, COVID-19 status, and treatment modalities. Risk factors for in-hospital mortality were identified using logistic regression and Cox proportional hazards models. The effect of surgical intervention was assessed through propensity score matching.

RESULTS

In-hospital mortality increased from 7.7% in 2019 to 26.4% in 2023, with an average annual growth of 38% (P = 0.008). The proportion of IE patients aged 65 years and older significantly increased, with this age group exhibiting the highest mortality rate (37.3%) by 2023. Surgical intervention was associated with a 91% reduction in in-hospital mortality (HR 0.09, 95% CI 0.05-0.15, P < 0.001). Independent risk factors for mortality included low left ventricular ejection fraction (LVEF), elevated heart rate (HR), cerebral hemorrhage, the use of vasoactive drugs and the requirement for continuous renal replacement therapy (CRRT).

CONCLUSION

In-hospital mortality due to IE in northern China has risen substantially since 2019, particularly in elderly patients and those with comorbid conditions. There was no significant change in overall per capita hospitalization costs or length of stay. Surgical intervention significantly improved survival outcomes. Additionally, patients who have been infected with COVID-19 twice had an 81.3% increased risk of death. The results of this study provide important data into the epidemiological and medical burden of IE in mainland China since the COVID-19 epidemic.

Multimodality Imaging Approach to Infective Endocarditis: Current Opinion in Patients with Congenital Heart Disease

Although advances in medical and surgical management have significantly improved clinical outcomes, infective endocarditis (IE) remains a significant threat to patients with congenital heart disease (CHD). The complexity of cardiac anatomy, the presence of prosthetic materials, and the emergence of novel pathogens pose unique diagnostic challenges in this specific population. However, the use of personalized imaging, integrating the strengths of each modality, has the potential to refine the diagnostic process, thereby optimizing diagnostic accuracy, guiding therapeutic decisions, and, ultimately, improving patient clinical outcomes. This review delves into the critical role of the multimodality imaging approach in the care of patients with IE and CHD, underscoring the importance of tailored and patient-centered management strategies in this vulnerable cohort.

Predictors of left atrial thrombi for subsequent thromboembolisms: Risk factors derived from echocardiography

BACKGROUND

Evidence regarding the management of left atrial thrombi (LATs) is limited.

OBJECTIVES

We aimed to investigate factors associated with subsequent thromboembolism in patients with LATs and explored potential management approaches.

METHODS

This multicenter retrospective study consecutively enrolled patients who underwent morphological assessment of LAT using echocardiography. We evaluated associations between clinical and echocardiographic variables and the occurrence of symptomatic thromboembolism.

RESULTS

Two hundred six patients from 15 centers were enrolled. During follow-up period after echocardiographic diagnosis (651 days; interquartile range 174-1316 days), 19 patients (9.2%) developed thromboembolism. Cox regression analysis identified 3 independent predictors of thromboembolism: LAT maximum length > 20 mm (hazard ratio [HR] 2.63; 95% confidence interval [CI] 1.03-6.68; P=.043), reduced left ventricular ejection fraction (≤40%) (HR 2.95; 95% CI 1.14-7.63; P=.026), and thrombus mobility (HR 3.40; 95% CI 1.27-9.11; P=.015). Patients with ≥2 of these factors (52 [25.2%]) were categorized as the high-risk group, while those with <2 factors (154 [74.8%]) formed the low-risk group. Patients in the high-risk group had a higher incidence of thromboembolism (12 [23.1%] vs 7 [4.5%]; P<.001), despite a higher proportion undergoing urgent surgical thrombectomy (UST; 9 [17.3%] vs 9 [5.8%]; P=.025) compared with the low-risk group. In high-risk patients, UST was associated with a significantly lower rate of adverse outcomes, including all-cause mortality, heart failure hospitalizations, major bleeding, and thromboembolisms, at 90 days (0% vs 35.6%; log-rank, P=.048).

CONCLUSION

In patients with LATs, large thrombus size, reduced left ventricular ejection fraction, and thrombus mobility were associated with subsequent thromboembolism. UST was associated with fewer adverse clinical outcomes in patients with ≥2 risk factors.

18-Fluorine-Fluorodeoxyglucose Positron Emission Computer Tomography Imaging in Melioidosis: Valuable but Not Essential

Melioidosis is an endemic tropical disease caused by Burkholderia pseudomallei. It typically causes pulmonary disease and bacteraemia but can disseminate to cause multi-organ disease. 18-F FDG PET/CT has an evolving role in diagnosing other infectious diseases, especially where the pathogen or extent of infection is challenging to elucidate clinically and with conventional imaging (CT, US and MRI). We present a case series of patients diagnosed with melioidosis who also underwent 18-F FDG PET/CT from December 18th 2018 to September 30th 2022. Indications for imaging were categorised and analysed as to whether 18-F FDG PET/CT changed management over conventional imaging. Twenty-one 18-F FDG PET/CT scans were performed for sixteen patients. Two scans (9.5%) performed for pyrexia of unknown origin changed management in both cases. Twelve scans (57.1%) performed to ascertain the extent of dissemination of melioidosis changed management in only three (25%) cases. Five scans (23.8%) performed to monitor the response to treatment of known foci changed management in all five cases. Five scans (23.8%) performed for suspected or known malignancy changed management in three (60%) cases. 18-F FDG PET/CT is an emerging tool which improves diagnosis and changes the management of melioidosis when applied judiciously and for well-selected indications.

Comparison between Duke, European Society of Cardiology 2015, International Society for Cardiovascular Infectious Diseases 2023, and European Society of Cardiology 2023 criteria for the diagnosis of transcatheter aortic valve replacement-related infective endocarditis

AIMS

Transcatheter aortic valve replacement-related infective endocarditis (TAVR-IE) is associated with a poor prognosis. TAVR-IE diagnosis is challenging, and benefits of the most recent classifications [European Society of Cardiology (ESC)-2015, International Society for Cardiovascular Infectious Diseases (ISCVID)-2023, and ESC-2023] have not been compared with the conventional Duke criteria on this population. The primary objective was to compare the diagnostic value of the Duke, ESC-2015, ISCVID-2023, and ESC-2023 criteria for the diagnosis of TAVR-IE. The secondary objectives were to determine which criteria increase the diagnostic accuracy of each classification and to evaluate in-hospital and 1-year mortality of TAVR-IE.

METHODS AND RESULTS

From January 2015 to May 2022, 92 patients with suspected TAVR-IE were retrospectively included in two French centres, including 82 patients with definite TAVR-IE and 10 patients with rejected TAVR-IE as defined by expert consensus. Duke classification yielded a sensitivity of 65% [95% confidence interval (CI): 53-75%] and a specificity of 100% (95% CI: 69-100%) for the diagnosis of TAVR-IE. ESC-2015 classification increased Duke criterion sensitivity from 65 to 73% (P = 0.016) but decreased specificity from 100 to 90%. ISCVID-2023 and ESC-2023 also increased Duke criterion sensitivity from 65 to 76% (P = 0.004) and 77% (P = 0.002), respectively, but also decreased specificity from 100 to 90%. A positive 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was the most helpful criterion, as 10 patients (11%) were correctly reclassified. In-hospital mortality after TAVR-IE was 21% and 1-year mortality was 38%.

CONCLUSION

A multimodality imaging approach, including 18F-FDG PET/CT and gated cardiac CT, is the cornerstone of TAVR-IE diagnosis and explains the higher sensitivity of ESC-2015 and recent classifications compared with Duke criteria.

Comprehensive CT study to assess local and systemic involvement in patients with infective endocarditis: experience from a multidisciplinary team of a tertiary referral center

PURPOSE

To evaluate the value of a computed tomography (CT) protocol, including ECG-gated cardiac angiographic and venous phase, in patients with infective endocarditis (IE).

MATERIAL AND METHODS

From January 2019 to October 2022, consecutive patients with IE submitted to total-body CT, including ECG-gated cardiac acquisition in angiographic and venous phase, were enrolled. Transesophageal echocardiography was performed in all cases. Rate of local complications including vegetation, pseudoaneurysm, abscess, fistula and valve dehiscence was compared in CT and echocardiography. Systemic embolization was identified through CT scans.

RESULTS

Seventy-six adults (median age 69 [IQR 55-77] years old; males 54/76, 71%] were enrolled. Most patients underwent surgery (51/76, 67%), and the in-hospital mortality rate was 8% (6/76). CT showed higher detection rate of valve vegetation compared to echocardiography (67/76, 88% vs 58/76, 76%; p = 0.008), including vegetation smaller than 10 mm (24/76, 36% vs 16/76, 28%; p = 0.013) and higher detection rate of pseudoaneurysm and abscess (p = 0.004 and p = 0.009, respectively). Abscess showed higher contrast-to-noise ratio (CNR) in the venous scan compared to angiographic scan (2.75 [IQR 2.27; 5.17] vs 1.97 [IQR 1.21; 3.32], p = 0.039) and higher density of perivalvular and epicardial fat compared to pseudoaneurysm (35 [IQR 31; 52]HU and - 50 [IQR - 62; - 35]HU versus 52 [IQR - 60; - 18]HU; p = 0.001, and - 91 [IQR - 95; - 81]HU; p = 0.007, respectively), for greater inflammation. CT overestimated valve dehiscence when compared to echocardiography and surgery.

CONCLUSION

A comprehensive CT study enhances the diagnostic assessment of patients with IE, not only by detecting distant sites of embolization, but also increasing sensitivity for valve vegetation and local complications.

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

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

The role of multimodal imaging in the diagnosis of prosthetic valve and intracardiac device endocarditis: A review

Infective endocarditis (IE) is a severe cardiac condition associated with substantial morbidity and mortality. Traditionally, the modified Duke's criteria have been used to establish the diagnosis of IE, which includes using transthoracic and transesophageal echocardiography. While echocardiography performs well in diagnosing native valve endocarditis, its diagnostic accuracy decreases in patients with prosthetic valves or implanted cardiac devices such as pacemakers and defibrillators. Given these limitations and advancements in cardiac imaging, including multimodal computed tomography, magnetic resonance imaging, and positron emission tomography, there has been growing interest in the utility of these techniques for diagnosing prosthetic valve endocarditis (PVE) and Cardiovascular implantable electronic device infection (CIEDI). Although numerous studies have investigated the value of these imaging modalities, their findings have been inconsistent. This article aims to reevaluate the role of advanced imaging in diagnosing PVE and CIEDI and its impact on managing prosthetic valves and device-related infective endocarditis. Methods A comprehensive literature search was conducted in PubMed, Cochrane library, Google Scholar, Embase, and other relevant databases. Key terms such as 'infective endocarditis,' 'multimodal imaging,' 'prosthetic valve endocarditis,' '18F-FDG PET,' 'cardiac MRI,' and 'cardiac CT' were used to identify studies that investigated the role of these imaging modalities in diagnosing PVE and CIEDI. Publications with full text including randomized controlled trials, retrospective studies, case reports, case series, reviews of literature, and society guidelines were included.

Amoxicillin Blood Concentration in High-Dose Intravenous Discontinuous Amoxicillin: Look Beyond Numbers. Max-Amox Study

PURPOSE

High doses of amoxicillin are recommended to treat severe infections such as endocarditis. Amoxicillin causes dose-dependent toxicities, in particular crystal nephropathy. Toxicity could be avoided by monitoring of amoxicillin trough plasma concentrations (ATPC). However, the relevance of ATPC testing in routine medical practice remains poorly studied.

METHODS

We conducted a prospective clinical trial in adults treated with high doses of discontinuous intravenous amoxicillin in a French university hospital. The primary outcome was the distribution of ATPCs over three days during the first week of treatment. Urine tests for amoxicillin crystalluria (AC), pH, and density were also performed.

FINDINGS

Seventy patients were included. Overall intra-class correlation (ICC) was 0.35 IC95% [0.21; 0.53] with the following pairwise concordances: D1-D4 (n= 55) 0.23 IC95% [-0.02; 0.47], D1-D7 (n= 47) 0.41 IC95% [0.19; 0.63], and D4-D7 (n= 50) 0.17 IC95% [-0.10; 0.43]. Inter-individual variability was also significant, with coefficients of variation being 0.87 at D1, 1.20 at D4, and 1.35 at D7. AC occurred in 32 patients (47.8%). Risk of AC increased when pH was below or equal to 6 (P = 0.002). ATPCs were higher in patients with AC and/or acute kidney injury.

IMPLICATIONS

Variability in ATPC was high and ATPC cannot be considered as the only monitoring tool to adjust amoxicillin dosage. High ATPC, low urinary pH, and presence of AC can alert physicians to a potential iatrogenic effect and lead to the decision to hydrate the patient, alkalinize urine and decrease the dosage of amoxicillin.

Point-of-care ultrasound diagnosis of acute valvular emergencies

INTRODUCTION

Acute valvular emergencies, a time-sensitive diagnosis, are nearly impossible to diagnose without ultrasound, and missing the diagnosis can significantly impact patient outcomes. Many emergency physicians lack access to echo technicians and may be uncomfortable performing the ultrasound themselves. Approaching the paucity of review articles, none of which are focused for the emergency physician, can be quite daunting, even for those with extensive ultrasound training.

OBJECTIVE

Our goal is to provide a simple resource for emergency physicians to utilize ultrasound to diagnose acute valvular emergencies. We created a concise review that includes relevance and approach to the diagnosis, complete with live ultrasound images, reference cards, and focused figures for in-the-moment reference.

METHODS

A team of ultrasound fellowship-trained emergency medicine physicians determined the highest yield emergent conditions and oversaw the project. Each team member reviewed the etiology, incidence, and level of evidentiary support for each condition and then provided a guide to the appropriate procedure and evaluation with relevant additional guidance. An in-house graphics team was consulted to prepare original, concise figures for easy reference. All sections of the manuscript and figures were reviewed for accuracy and ease of use.

DISCUSSION

Critical aortic stenosis, infective endocarditis, left ventricular outflow tract obstruction, mitral stenosis, and mitral regurgitation were identified diagnoses for which ultrasound can provide immediate diagnostic information for emergency physicians.

CONCLUSION

The use of ultrasound in the emergency department setting is a critical adjunct to care for patients with acute valvular emergencies. One should always consider a comprehensive, cardiology-performed echocardiogram in these scenarios.

Decision making in surgery: honoring patient autonomy despite high mortality risk in a 36-year-old woman with endocarditis

Infective endocarditis (IE) is a common complication in patients who inject drugs. We present the case of a 36-year-old woman with IE affecting both the aortic and tricuspid valves, along with a cardiac implantable electronic device infection, 11 weeks after combined aortic valve replacement, tricuspid valve replacement, and pacemaker implantation. The patient declined the medically indicated cardiac surgery due to her recent taxing surgical and rehabilitation experiences. Clear preoperative communication was crucial to align the patient's goals with available treatment options. Decision making was achieved through multiple interdisciplinary discussions, fostering openness, and dialog. This case highlights the challenges of surgical decision making and provides a valuable example of a patient-centered approach to informed consent within a multidisciplinary team. Moreover, it demonstrates the successful integration of palliative care into surgical management.

A national study of infective endocarditis models of care in Australia

BACKGROUND

Multidisciplinary endocarditis team (MDET) management is supported by current evidence and recommended in international society guidelines. The extent to which this recommendation has been implemented in Australian centres and the attitudes, barriers and facilitators of this model are unclear.

AIM

To describe current infective endocarditis (IE) models of care in Australian specialist referral centres and evaluate facilitators, barriers and attitudes towards MDET implementation.

METHODS

Aims were addressed using two online surveys. Survey 1 audited IE models of care and was distributed to infectious disease physicians at specialist referral centres. Survey 2 assessed barriers, facilitators and attitudes towards MDETs and was distributed via societal email listings.

RESULTS

From 56 identified cardiac surgery centres, survey 1 received 47 responses (84%). A total of 28% (13/47) of participating institutions had an existing MDET. A total of 85% (11/13) of MDETs were in public hospitals and 85% (11/13) were in high IE volume centres. Survey 2 had 109 respondents from seven specialties. Attitudes towards MDET implementation were generally favourable. Identified barriers to MDET implementation included a lack of funding, resources, expertise, time and collaboration. Facilitators included strong leadership, engagement from key stakeholders and tangible benefits.

CONCLUSIONS

Even though it is recommended in international guidelines, the MDET model is used by less than one-third of Australian specialist referral centres. Stakeholders in IE care have generally favourable attitudes towards MDET implementation but cite a lack of resources, funding, collaboration and time as barriers to this. Dedication of financial and administrative support and leadership from key stakeholders are required to increase MDET utilisation.

Knowledge, Attitudes, and Practices of Moroccan Rheumatologists in the Management of Acute Septic Arthritis: Results of a National Cross-Sectional Survey

Objective To assess the level of knowledge of Moroccan rheumatologists regarding the management of acute septic arthritis and analyze their attitudes and clinical practices toward this condition. Methods A descriptive cross-sectional study was conducted among Moroccan rheumatologists through a Google Forms questionnaire distributed via email. The data collected included sociodemographic characteristics of Moroccan rheumatologists, their level of knowledge, as well as their attitudes and clinical practices, assessed on a Likert scale (1 to 5). Results Out of the 440 questionnaires sent, 131 rheumatologists replied, corresponding to a response rate of 131 (33.58%). The average age of participants was 42.9±12.7 years, with a predominance of females (103 (84.8%)) and an average of 13.8 ± 11.3 years of experience in rheumatology. The diagnosis of septic arthritis was systematically considered in the case of acute monoarthritis, even in the absence of fever, by 122 (93.1%) rheumatologists. However, only 68 (51.9%) were aware of the association between a quick Sequential Organ Failure Assessment (qSOFA) score ≥2 and a high risk of mortality. Regarding therapeutic management, 115 (87.8%) rheumatologists preferred a third-generation cephalosporin, often combined with an aminoglycoside (110 (84%)). However, only 18 (13.7%) prescribed short-course antibiotics for small joints, and 13 (9.9%) associated this with joint lavage and/or surgical synovectomy. Furthermore, in cases of unfavorable evolution, only 19 (14.5%) routinely referred the patient to an orthopedic surgeon for surgical lavage. The main challenges identified were delayed diagnosis (90 (68.7%)) and the management of complicated cases (91 (69.5%)). To address these issues, a large majority of rheumatologists recommended the development of standardized protocols (118 (90.1%)), raising awareness among healthcare professionals about early diagnosis (116 (88.5%)), and strengthening collaboration with orthopedic surgeons (111 (84.7%)). Conclusion This study highlights gaps in the management of acute septic arthritis and emphasizes the need for better awareness, standardization of practices, and improved coordination with other specialties to optimize patient care.

Emergence of Infective Endocarditis Due to Serratia spp.: Results of a Multicenter Cohort

Background

Infective endocarditis due to Serratia spp. (S-IE) has historically been considered a rare entity. Typically linked to injection drug use (IDU), S-IE appears to be a growing problem as the harms of unsafe drug use proliferate. However, guidance on therapy for Gram-negative IE remains limited.

Methods

This was a retrospective analysis of adults treated for S-IE at 4 academic health systems in different US states from 2015 to 2021. Multivariable logistic regression analyzed the association of inpatient mortality with procedural management and combination antibiotic treatment.

Results

A total of 159 cases of S-IE were identified with a qualitative overall increase across the period, and a peak in 2019, although trends varied by site. Seventy-five were due to IDU, 57% involved a single left-sided valve, and inpatient mortality was 21%. In adjusted analyses, including 117 cases from 3 sites, lower inpatient mortality was associated with procedural intervention (odds ratio 0.14; 95% confidence interval, .03-.64) and combination antibiotic therapy (odds ratio 0.15; 95% confidence interval, .03-.74).

Discussion

In this multicenter study, we found that S-IE may be increasing, is commonly associated with IDU, is treated with varying strategies and carries high inpatient mortality. Procedural intervention and combination antibiotics were associated with lower mortality. Our study is limited by varying methods of case identification and a lack of data on clinical severity and surgical indications. Further study is urgently needed to define best management practices.

The Ross Procedure in Active Infective Endocarditis: A Comparison With Conventional Prostheses

Background

The Ross procedure can be an ideal option in infective endocarditis (IE) due to greater resistance to infection. However, limited literature has highlighted the comparison with conventional prostheses in this setting.

Methods

Between February 2013 and September 2022, 25 patients (median age, 50 years) underwent a Ross procedure for IE (Ross group). The results were compared with those after other aortic valve procedures (aortic valve replacement and aortic root replacement) for IE (n = 37, other group.

Results

The patients in the Ross group included more intravenous drug users and had more prosthetic valve endocarditis and annular abscess formation compared with the other group. Although cardiopulmonary bypass time and aortic cross-clamp time were significantly longer (P < .001 and P = .003, respectively) and the blood requirements were significantly higher (P = .001) in the Ross group, most postoperative short-term outcomes were equivalent between the 2 groups. During follow-up, 1 patient (4%) required reoperation in the Ross group, whereas 6 patients (16%) required reoperation in the other group. Freedom from composite events was significantly better in the Ross group (P = .04). Multivariable analysis found the Ross procedure, compared with other procedures, was a significant independent protective factor for composite end points (P = .03).

Conclusions

For IE, despite surgical complexity, the Ross procedure yielded short-term outcomes similar to other procedures. In the midterm, the Ross procedure provides a lower reoperation rate, resulting in significantly fewer composite events. The Ross procedure appears to be a better option for patients with IE, but long-term follow-up is necessary.

Silent strike: stroke in context of endocarditis - brain imaging as a catalyst for diagnosis

INTRODUCTION

Endocarditis is a pathology which is rarely encountered in clinical practice that presents itself in various manners, thus posing a great challenge for the clinician in the process of formulating a timely diagnosis, especially given its potentially lethal evolution. The diagnosis of infective endocarditis is based on Modified Duke Criteria. A wide array of complications may accompany endocarditis, including septic or thrombotic emboli to various territories - those occluding branches of cerebral arteries result in ischemic strokes, which may be demonstrated by brain imaging and the symptoms which may range from mild mental status alteration to deep coma. Objective: Assessment of brain imaging as a diagnostic tool for bacterial endocarditis.

MATERIALS AND METHODS

This is a nested case-control study, in which 84 patients with ischemic stroke were enrolled, half of them having endocarditis related stroke (cases), and the other half stroke due to cardioembolism from other sources or to large-artery atherosclerosis (controls).

RESULTS

Brain imaging revealed statistically significant differences between the two cohorts, endocarditis related stroke being more strongly associated with multiple territories involvement, multiple lesions coexistence, watershed lesions, and a greater extent of ischemia all these may serve as valuable diagnostic clues. Among these findings, the presence of multiple lesions has been the most sensitive tool (Sn = 0.786, Sp = 0.857, LR+ = 5.497, LR- = 0.25), while the involvement of multiple arterial territories had the highest specificity and positive likelihood ratio for endocarditis-related stroke (Sn = 0.738, Sp = 0.929, LR+ = 10.394, LR- = 0.282). A larger ischemic lesion as quantified by pc-ASPECTS score (more than by the ASPECTS score) also increases the likelihood of endocarditis as the cause of ischemic stroke, with an AUROC of 0.7361 (95% CI 0.629-0.843).

CONCLUSIONS

Early brain imaging could play a crucial role in endocarditis, helping the clinician to suspect this diagnosis. Further studies are needed to understand the role of early brain imaging when Modified Duke Criteria fail to establish the diagnosis.

Rare Case of Early Mycotic Ascending Aortic Aneurysm Following Transcatheter Aortic Valve Replacement

Prosthetic valve endocarditis, though a rare complication, carries a high risk of morbidity and mortality. Mycotic aneurysms are even less common and have been reported in association with femoral access (femoral artery aneurysms) following transcatheter aortic valve replacement (TAVR). We describe a rare case of a mycotic aneurysm that developed in the ascending aorta after a TAVR procedure.

Advantages and Challenges of Using Antimicrobial Peptides in Synergism with Antibiotics for Treating Multidrug-Resistant Bacteria

Multidrug-resistant bacteria (MDR) have become a global threat, impairing positive outcomes in many cases of infectious diseases. Treating bacterial infections with antibiotic monotherapy has become a huge challenge in modern medicine. Although conventional antibiotics can be efficient against many bacteria, there is still a need to develop antimicrobial agents that act against MDR bacteria. Bioactive peptides, particularly effective against specific types of bacteria, are recognized for their selective and effective action against microorganisms and, at the same time, are relatively safe and well tolerated. Therefore, a growing number of works have proposed the use of antimicrobial peptides (AMPs) in synergism with commercial antibiotics as an alternative therapeutic strategy. This review provides an overview of the critical parameters for using AMPs in synergism with antibiotics as well as addressing the strengths and weaknesses of this combination therapy using in vitro and in vivo models of infection. We also cover the challenges and perspectives of using this approach for clinical practice and the advantages of applying artificial intelligence strategies to predict the most promising combination therapies between AMPs and antibiotics.

Men's more frequent predisposing factors in infectious endocarditis facilitate improvement of outcomes by shortening of diagnostic delay

Introduction

Despite growing evidence for sex-specific differences in cardiovascular disease, sex is poorly considered in the management of infectious endocarditis (IE).

Purpose

This study aimed to assess sex-specific aspects in diagnosing IE.

Methods

All consecutive patients admitted at Ulm University Heart Center with suspected IE between 2009 and 2019 were included. IE was diagnosed using the Duke criteria. Risk factors, clinical presentation and in-hospital outcomes along with the impact of diagnostic delay were compared between male and female patients.

Results

IE was diagnosed in 96 of 118 men (81.4%) and 33 of 45 women (73.3%) (p = 0.121). Time to diagnosis was similar between the groups (p = 0.598). Regarding patient characteristics, men were younger (65.5 vs. 74.3 years, p = 0.006). Men exhibited a higher prevalence of predisposing cardiac conditions (p = 0.012) due to a higher frequency of a history of implantable cardioverter defibrillator implantation (p = 0.004), and were more likely to have poor dental status (p = 0.001), and coronary artery disease (p = 0.002). The incidence of the complications of heart failure with reduced ejection fraction (p = 0.007) and new-onset dialysis (p = 0.012) were higher, the time in the intensive care unit (p = 0.012) longer. Male sex was the only independent risk factor for in-hospital mortality [p = 0.036, HR 4.127 (95%-CI 1.096-15.538)]. Notably, only in the male cohort, a shorter time to diagnosis was associated with a lower mortality rate (p = 0.035, optimal cut-point 3.5 days). Men diagnosed within 3.5 days had a mortality rate of 13.5% compared to 31.8% for those diagnosed later (p = 0.028).

Conclusion

Men with suspected IE are younger, have more predisposing factors and experience a more complicated course of disease, while benefiting from early diagnosis. Therefore, recognizing the heightened risk profile specific to men during diagnosis can help to address their poorer prognosis.

Fifteen years of experience with the melody™ TPV for percutaneous pulmonary valve replacement

BACKGROUND

The Melody™ TPV has been used as an alternative to surgical pulmonary valve replacement; limited medium-term follow-up data are available.

AIMS

To report the follow-up data of all Melody™ TPVs implanted locally over a 15-year period (2006-2021).

METHODS

Single-centre non-randomised prospective observational study of all implanted Melody™ valves in the pulmonary position.

RESULTS

234 Melody™ valves were implanted at a mean age of 20.8 ± 24.6y. Indications for valve implantation included: pulmonary stenosis (47.2%,) regurgitation (30.9%), and mixed pathology (21.9%). The implant zone substrate consisted of homograft in 52.6%, patched right ventricular outflow tract in 33.8%, and bioprostheses in 13.6% of the cases. Valve survival at 10 years was 89% and 72% at 15 years follow-up. Pulmonary stenosis and pulmonary and tricuspid valve regurgitation demonstrated no significant evolution over the 15-year follow-up. Over the study period, there were 7 deaths at a mean age of 54.2 ± 21.1y; none was valve related. Valve failure was observed in 22 cases (9.4%), mainly due to endocarditis 13/22 (59.0%). The overall incidence of endocarditis was 1.5% per patient-year and occurred in 10.2% (n = 24) of patients 2.7 ± 1.6y after TPV, mostly in younger men (median 18.3, range 8.1 - 49.5 y). Balloon dilatation to accommodate for somatic growth was successful in all 17 (7.3%) attempted cases.

CONCLUSION

The Melody™ valve had a low risk for valve failure with overall well-preserved valve function over up to 15 years of follow-up. Endocarditis remains a concern. The Melody™ valve is competitive with other surgical and percutaneous conduits.