Endocarditis in the intensive care unit: an update

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.

Unsolved Controversies in Management of Infective Endocarditis

Infective endocarditis (IE) is defined as an infection in the cardiac endothelium. It is triggered by both bacteremia and endothelial dysfunction and poses many risks to the health of the patient. Many organisms can cause IE with Staphylococcus aureus being the major cause. Signs and symptoms may vary according to age and agent but almost all cases are presented with fever, fatigue, and a maculopapular rash. Although pediatric IE is very rare, risk factors such as congenital heart defects have been identified, with some of the cases remaining a mystery. We present a case of a 19-year-old patient, previously healthy and developing subacute IE with sepsis and septic embolic showers in multiple organs. IE cannot be taken for granted as mortality is high, hence a multidisciplinary approach is prompt and necessary for the survival of the patient.

The impact of concomitant infective endocarditis in patients with spondylodiscitis and isolated spinal epidural empyema and the diagnostic accuracy of the modified duke criteria

Background

The co-occurrence of infective endocarditis (IE) and primary spinal infections (PSI) like spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been reported in up to 30% of cases and represents a life-threatening infection that requires multidisciplinary management to be successful. Therefore, we aimed to characterize the clinical phenotypes of PSI patients with concomitant IE and furthermore to assess the accuracy of the modified Duke criteria in this specific population.

Methods

We conducted a retrospective cohort study in consecutive SD and ISEE patients treated surgically at our University Spine Center between 2002 and 2022 who have undergone detailed phenotyping comprising demographic, clinical, imaging, laboratory, and microbiologic assessment. Comparisons were performed between PSI patients with IE (PSICIE) and without IE (PSIWIE) to identify essential differences.

Results

Methicillin-susceptible Staphylococcus aureus (MSSA) was the most common causative pathogen in PSICIE group (13 patients, 54.2%) and aortic valve IE was the most common type of IE (12 patients, 50%), followed by mitral valve IE (5 patients, 20.8%). Hepatic cirrhosis (p < 0.011; OR: 4.383; 95% CI: 1.405-13.671), septic embolism (p < 0.005; OR: 4.387; 95% CI: 1.555-12.380), and infection with Streptococcus spp. and Enterococcus spp. (p < 0.003; OR: 13.830; 95% CI: 2.454-77.929) were identified as significant independent risk factors for the co-occurrence of IE and PSI in our cohort. The modified Duke criteria demonstrated a sensitivity of 100% and a specificity of 66.7% for the detection of IE in PSI patients. Pathogens were detected more frequently via blood cultures in the PSICIE group than in the PSIWIE group (PSICIE: 23, 95.8% vs. PSIWIE: 88, 62.4%, p < 0.001). Hepatic cirrhosis (PSICIE: 10, 41.7% vs. PSIWIE: 33, 21.6%, p = 0.042), pleural abscess (PSICIE: 9, 37.5% vs. PSIWIE: 25, 16.3%, p = 0.024), sepsis (PSICIE: 20, 83.3% vs. PSIWIE: 67, 43.8%, p < 0.001), septic embolism (PSICIE: 16/23, 69.6% vs. PSIWIE: 37/134, 27. 6%, p < 0.001) and meningism (PSICIE: 8/23, 34.8% vs. PSIWIE: 21/152, 13.8%, p = 0.030) occurred more frequently in PSICIE than in PSIWIE patients. PSICIE patients received longer intravenous antibiotic therapy (PSICIE: 6 [4-7] w vs. PSIWIE: 4 [2.5-6] w, p < 0.001) and prolonged total antibiotic therapy overall (PSICIE: 11 [7.75-12] w vs. PSIWIE: 8 [6-12] w, p = 0.014). PSICIE patients spent more time in the hospital than PSIWIE (PSICIE: 43.5 [33.5-53.5] days vs. PSIWIE: 31 [22-44] days, p = 0.003).

Conclusions

We report distinct clinical, radiological, and microbiological phenotypes in PSICIE and PSIWIE patients and further demonstrate the diagnostic accuracy of the modified Duke criteria in patients with PSI and concomitant IE. In the high-risk population of PSI patients, the modified Duke criteria might benefit from amending pleural abscess, meningism, and sepsis as minor criteria and hepatic cirrhosis as major criterion.

Endocarditis in critically ill patients: a review

PURPOSE OF REVIEW

To summarize the advances in literature that support the best current practices regarding infective endocarditis (IE) in critically ill patients.

RECENT FINDINGS

IE due to rheumatic diseases has decreased significantly, and in fact, the majority of cases are associated with degenerative valvopathies, prosthetic valves, and cardiovascular implantable electronic devices. The Duke criteria were recently updated, addressing the increasing incidence of new risk factors for IE, such as IE associated with the use of endovascular cardiac implantable electronic devices and transcatheter implant valves. The presence of organ dysfunction, renal replacement therapies, or extracorporeal membrane oxygenation should be considered in the choice of drug and dosage in critically ill patients with suspected or confirmed IE. As highlighted for other severe infections, monitoring of therapeutic antibiotic levels is a promising technique to improve outcomes in critically ill patients with organ dysfunction.

SUMMARY

The diagnostic investigation of IE must consider the current epidemiological criteria and the diagnostic particularities that these circumstances require. A careful evaluation of these issues is necessary for the prompt clinical or surgical management of this infection.

Perioperative Complications in Infective Endocarditis

Infective endocarditis is a challenging condition to manage, requiring collaboration among various medical professionals. Interdisciplinary teamwork within endocarditis teams is essential. About half of the patients diagnosed with the disease will ultimately have to undergo cardiac surgery. As a result, it is vital for all healthcare providers involved in the perioperative period to have a comprehensive understanding of the unique features of infective endocarditis, including clinical presentation, echocardiographic signs, coagulopathy, bleeding control, and treatment of possible organ dysfunction. This narrative review provides a summary of the current knowledge on the incidence of complications and their management in the perioperative period in patients with infective endocarditis.