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Ramos-Martínez A, Domínguez F, Muñoz P, Marín M, Pedraz Á, Fariñas MC, Tascón V, de Alarcón A, Rodríguez-García R, Miró JM, Goikoetxea J, Ojeda-Burgos G, Escrihuela-Vidal F, Calderón-Parra J. Clinical presentation, microbiology, and prognostic factors of prosthetic valve endocarditis. Lessons learned from a large prospective registry. PLoS One 2023; 18:e0290998. [PMID: 37682961 PMCID: PMC10490835 DOI: 10.1371/journal.pone.0290998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/19/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Prosthetic valve endocarditis (PVE) is a serious infection associated with high mortality that often requires surgical treatment. METHODS Study on clinical characteristics and prognosis of a large contemporary prospective cohort of prosthetic valve endocarditis (PVE) that included patients diagnosed between January 2008 and December 2020. Univariate and multivariate analysis of factors associated with in-hospital mortality was performed. RESULTS The study included 1354 cases of PVE. The median age was 71 years with an interquartile range of 62-77 years and 66.9% of the cases were male. Patients diagnosed during the first year after valve implantation (early onset) were characterized by a higher proportion of cases due to coagulase-negative staphylococci and Candida and more perivalvular complications than patients detected after the first year (late onset). In-hospital mortality of PVE in this series was 32.6%; specifically, it was 35.4% in the period 2008-2013 and 29.9% in 2014-2020 (p = 0.031). Variables associated with in-hospital mortality were: Age-adjusted Charlson comorbidity index (OR: 1.15, 95% CI: 1.08-1.23), intracardiac abscess (OR:1.78, 95% CI:1.30-2.44), acute heart failure related to PVE (OR: 3. 11, 95% CI: 2.31-4.19), acute renal failure (OR: 3.11, 95% CI:1.14-2.09), septic shock (OR: 5.56, 95% CI:3.55-8.71), persistent bacteremia (OR: 1.85, 95% CI: 1.21-2.83) and surgery indicated but not performed (OR: 2.08, 95% CI: 1.49-2.89). In-hospital mortality in patients with surgical indication according to guidelines was 31.3% in operated patients and 51.3% in non-operated patients (p<0.001). In the latter group, there were more cases of advanced age, comorbidity, hospital acquired PVE, PVE due to Staphylococcus aureus, septic shock, and stroke. CONCLUSIONS Not performing cardiac surgery in patients with PVE and surgical indication, according to guidelines, has a significant negative effect on in-hospital mortality. Strategies to better discriminate patients who can benefit most from surgery would be desirable.
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Affiliation(s)
- Antonio Ramos-Martínez
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital Puerta de Hierro, Majadahonda, Spain
- Instituto Investigación Sanitaria Puerta de Hierro—Segovia de Arana (IDIPHSA), Majadahonda, Spain
- Autonomous University of Madrid, Majadahonda, Spain
| | - Fernando Domínguez
- Department of Cardiology, University Hospital Puerta de Hierro, Majadahonda, Spain
| | - Patricia Muñoz
- Department of Cardiology, University Hospital Puerta de Hierro, Majadahonda, Spain
- Department of Clinical Microbiology and Infectious Diseases, University General Hospital Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
| | - Mercedes Marín
- Department of Clinical Microbiology and Infectious Diseases, University General Hospital Gregorio Marañón, Madrid, Spain
- CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
| | - Álvaro Pedraz
- Department of Cardiac Surgery, University General Hospital Gregorio Marañón, Madrid, Spain
| | - Mª Carmen Fariñas
- Department of Infectious Diseases, University Hospital Marqués de Valdecilla-IDIVAL, Santander, Spain
- CIBER de Enfermedades Infecciosas-CIBERINFEC (CB21/13/00068), Institute of Health Carlos III, Madrid, Spain
- University of Cantabria, Santander, Spain
| | - Valentín Tascón
- Department of Cardiovascular Surgery, University Hospital Marqués de Valdecilla, Santander, Spain
| | - Arístides de Alarcón
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Infectious Diseases Research Group Institute of Biomedicine of Seville (IBiS), Seville, Spain
- University of Seville/CSIC/University, Seville, Spain
- Hospital Virgen del Rocío, Seville, Spain
| | - Raquel Rodríguez-García
- Department of Intensive Medicine, University Hospital Central of Asturias, Oviedo, Spain
- University of Oviedo, Oviedo, Spain
| | - José María Miró
- Infectious Diseases Service, Hospital Clinic-IDIBAPS, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
| | - Josune Goikoetxea
- Department of Infectious Diseases, University Hospital de Cruces, Bilbao, Spain
| | - Guillermo Ojeda-Burgos
- Department of Internal Medicine, University Hospital Virgen de la Victoria, Málaga, Spain
| | - Francesc Escrihuela-Vidal
- University of Barcelona, Barcelona, Spain
- Department of Infectious Diseases, University Hospital of Bellvitge, Barcelona, Spain
- Research Institut of Biomedicine of Bellvitge, Barcelona, Spain
| | - Jorge Calderón-Parra
- Unit of Infectious Diseases, Department of Internal Medicine, University Hospital Puerta de Hierro, Majadahonda, Spain
- Instituto Investigación Sanitaria Puerta de Hierro—Segovia de Arana (IDIPHSA), Majadahonda, Spain
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Oberbach A, Schlichting N, Hagl C, Lehmann S, Kullnick Y, Friedrich M, Köhl U, Horn F, Kumbhari V, Löffler B, Schmidt F, Joskowiak D, Born F, Saha S, Bagaev E. Four decades of experience of prosthetic valve endocarditis reflect a high variety of diverse pathogens. Cardiovasc Res 2022; 119:410-428. [PMID: 35420122 DOI: 10.1093/cvr/cvac055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/04/2022] [Accepted: 03/23/2022] [Indexed: 01/18/2023] Open
Abstract
Prosthetic valve endocarditis (PVE) remains a serious condition with a high mortality rate. Precise identification of the PVE-associated pathogen/s and their virulence is essential for successful therapy, and patient survival. The commonly described PVE-associated pathogens are staphylococci, streptococci and enterococci, with Staphylococcus aureus being the most frequently diagnosed species. Furthermore, multi-drug resistance pathogens are increasing in prevalence, and continue to pose new challenges mandating a personalized approach. Blood cultures in combination with echocardiography are the most common methods to diagnose PVE, often being the only indication, it exists. In many cases, the diagnostic strategy recommended in the clinical guidelines does not identify the precise microbial agent and to frequently, false negative blood cultures are reported. Despite the fact that blood culture findings are not always a good indicator of the actual PVE agent in the valve tissue, only a minority of re-operated prostheses are subjected to microbiological diagnostic evaluation. In this review, we focus on the diversity and the complete spectrum of PVE-associated bacterial, fungal and viral pathogens in blood, and prosthetic heart valve, their possible virulence potential, and their challenges in making a microbial diagnosis. We are curious to understand if the unacceptable high mortality of PVE is associated with the high number of negative microbial findings in connection with a possible PVE. Herein, we discuss the possibilities and limits of the diagnostic methods conventionally used and make recommendations for enhanced pathogen identification. We also show possible virulence factors of the most common PVE-associated pathogens and their clinical effects. Based on blood culture, molecular biological diagnostics, and specific valve examination, better derivations for the antibiotic therapy as well as possible preventive intervention can be established in the future.
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Affiliation(s)
- Andreas Oberbach
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany.,Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany
| | - Nadine Schlichting
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany.,Munich Heart Alliance, Partner Site German Centre for Cardiovascular Disease (DZHK), Munich, Germany
| | - Stefanie Lehmann
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Yvonne Kullnick
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Maik Friedrich
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Ulrike Köhl
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Friedemann Horn
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Florida, USA
| | - Bettina Löffler
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Frank Schmidt
- Proteomics Core, Weill Cornell Medical Centre Qatar, Doha, Qatar
| | - Dominik Joskowiak
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Frank Born
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Shekhar Saha
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Erik Bagaev
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
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