Healthcare-associated infective endocarditis: an undesirable effect of healthcare universalization

Healthcare-associated infective endocarditis: source of infection and burden of previous healthcare exposure

Objective

Prevention of healthcare-associated infective endocarditis (HAIE) is based on characterization of underlying factors. Our object was to describe the source of infection, microbiological etiology, and healthcare-related risk factors for HAIE.

Design

Retrospective population-based study.

Patients

Adult patients diagnosed with HAIE during 2013-2017 who resided in the study area in Southern Finland with adult population of 0.9 million.

Results

Ninety-five HAIE episodes were included. Ten episodes were related to cardiac surgery. Of the remaining 85 episodes, 11 were classified as nosocomial (ie, acquired and diagnosed during ongoing hospitalization) and 74 as non-nosocomial HAIE. Staphylococcus aureus caused 45% of nosocomial episodes, but only 16% of non-nosocomial episodes (P = 0.039). Most common sources of infection in non-nosocomial HAIE were previous hospitalization (24%), dialysis (18%), and urologic procedures (15%). Enterococcus spp. caused 23% of non-nosocomial HAIE, and more than half of them were associated with urologic or gastrointestinal procedures. Two-thirds of the non-nosocomial HAIE patients had recent hospitalization or invasive procedure. We counted previous healthcare-related risk factors for IE and those who had two or more of them had higher in-hospital and one-year mortality.

Conclusion

Our study indicates the importance of non-nosocomial acquisition of HAIE and S. aureus as the major pathogen in nosocomial episodes. Enterococcal infections dominate in non-nosocomial cases and further studies are needed to identify patients at risk for enterococcal IE after urological or gastrointestinal procedure.

Non-nosocomial Healthcare-Associated Infective Endocarditis: A Distinct Entity? Data From the GAMES Series (2008-2021)

Background

Patients who acquire infective endocarditis (IE) following contact with the healthcare system, but outside the hospital, are classified as having non-nosocomial healthcare-associated IE (HCIE). Our aim was to characterize HCIE and establish whether its etiology, diagnosis, and therapeutic approach suggest it should be considered a distinct entity.

Methods

This study retrospectively analyzes data from a nationwide, multicenter, prospective cohort including consecutive cases of IE at 45 hospitals across Spain from 2008 to 2021. HCIE was defined as IE detected in patients in close contact with the healthcare system (eg, patients receiving intravenous treatment, hemodialysis, or institutionalized). The prevalence and main characteristics of HCIE were examined and compared with those of community-acquired IE (CIE) and nosocomial IE (NIE) and with literature data.

Results

IE was diagnosed in 4520 cases, of which 2854 (63%) were classified as CIE, 1209 (27%) as NIE, and 457 (10%) as HCIE. Patients with HCIE showed a high burden of comorbidities, a high presence of intravascular catheters, and a predominant staphylococcal etiology, Staphylococcus aureus being identified as the most frequent causative agent (35%). They also experienced more persistent bacteremia, underwent fewer surgeries, and showed a higher mortality rate than those with CIE (32.4% vs 22.6%). However, mortality in this group was similar to that recorded for NIE (32.4% vs 34.9%, respectively, P = .40).

Conclusions

Our data do not support considering HCIE as a distinct entity. HCIE affects a substantial number of patients, is associated with a high mortality, and shares many characteristics with NIE.

A Rare Case of Bartonella henselae Infective Endocarditis Causing an Embolic Cerebrovascular Accident

Bartonella is a facultative intracellular Gram-negative aerobic rod that is an important cause of culture-negative endocarditis that only accounts for 3% of all infective endocarditis (IE) cases. Throughout the literature, there have been very few documented cases of an embolic stroke caused by Bartonella henselae (B. henselae) IE. Following a comprehensive review of the literature, it appears that only a small number of articles have reported on the correlation between cerebrovascular accidents (CVAs) and Bartonella IE. Here, we present a case of a 42-year-old male with a cerebral embolic event as a complication of B. henselae IE.

Limiting Factors in Treatment Success of Biofilm-Forming Streptococci in the Case of Canine Infective Endocarditis Caused by Streptococcus canis

An 8-year-old male Rhodesian Ridgeback was presented with fever and severe thrombocytopenia. Clinical and laboratory examination, echocardiography, blood culture, and pathohistology revealed evidence of infective endocarditis, ischemic renal infarcts, and septic encephalitis. Treatment was started immediately but the dog's condition worsened, and the dog had to be euthanized. The causative Streptococcus canis strain was detected by blood culture and MALDI-TOF MS and analyzed using whole-genome sequencing and multilocus sequence typing. Antibiotic susceptibility testing did not detect any resistance. The affected heart valve was analyzed using FISH imaging, which showed a streptococcal biofilm on the heart valve. Bacteria in biofilms are recalcitrant to antibiotic treatment. Early diagnosis could be beneficial to treatment outcome. Treatment of endocarditis could be improved by researching the optimal dosage of antibiotics in conjunction with the use of biofilm-active drugs.

Treatment of Enterococcus faecalis Infective Endocarditis: A Continuing Challenge

Today, Enterococcus faecalis is one of the main causes of infective endocarditis in the world, generally affecting an elderly and fragile population, with a high mortality rate. Enterococci are partially resistant to many commonly used antimicrobial agents such as penicillin and ampicillin, as well as high-level resistance to most cephalosporins and sometimes carbapenems, because of low-affinity penicillin-binding proteins, that lead to an unacceptable number of therapeutic failures with monotherapy. For many years, the synergistic combination of penicillins and aminoglycosides has been the cornerstone of treatment, but the emergence of strains with high resistance to aminoglycosides led to the search for new alternatives, like dual beta-lactam therapy. The development of multi-drug resistant strains of Enterococcus faecium is a matter of considerable concern due to its probable spread to E. faecalis and have necessitated the search of new guidelines with the combination of daptomycin, fosfomycin or tigecycline. Some of them have scarce clinical experience and others are still under investigation and will be analyzed in this review. In addition, the need for prolonged treatment (6–8 weeks) to avoid relapses has forced to the consideration of other viable options as outpatient parenteral strategies, long-acting administrations with the new lipoglycopeptides (dalbavancin or oritavancin), and sequential oral treatments, which will also be discussed.

Treatment and outcome of gram-positive bacteremia in patients receiving extracorporeal membrane oxygenation

BACKGROUND

While guidance exists for management of blood stream infections with various invasive devices, there are currently limited data to guide antibiotic selection and duration for bacteremia in patients receiving extracorporeal membrane oxygenation (ECMO).

OBJECTIVE

To evaluate the treatment and outcomes of thirty-six patients with Staphylococcus aureus and Enterococcus bacteremia on ECMO support.

METHODS

Blood culture data was retrospectively analyzed from patients with Staphylococcus aureus bacteremia (SAB) or Enterococcus bacteremia who underwent ECMO support between March 2012 and September 2021 at Brooke Army Medical Center.

RESULTS

Of the 282 patients who received ECMO during this study period, there 25 (9%) patients developed Enterococcus bacteremia and 16 (6%) developed SAB. SAB occurred earlier in ECMO as compared to Enterococcus (median day 2 IQR (1-5) vs. 22 (12-51), p = 0.01). The most common duration of antibiotics was 28 days after clearance for SAB and 14 days after clearance for Enterococcus. 2 (5%) patients underwent cannula exchange with primary bacteremia, and 7 (17%) underwent circuit exchange. 1/3 (33%) patients with SAB and 3/10 (30%) patients with Enterococcus bacteremia who remained cannulated after completion of antibiotics had a second episode of SAB or Enterococcus bacteremia.

CONCLUSION

This single center case series is the first to describe the specific treatment and outcomes of patients receiving ECMO complicated by SAB and Enterococcus bacteremia. For patients who remain on ECMO after completion of antibiotics, there is a risk of a second episode of Enterococcus bacteremia or SAB.

[Global and national trends in the evolution of infective endocarditis]

For the recent 20 years, substantial changes have occurred in all aspects of infectious endocarditis (IE), the evolution of risk factors, modernization of diagnostic methods, therapeutic and preventive approaches. The global trends are characterized by increased IE morbidity among people older than 65 who use intravenous psychoactive drugs. The epidemiological trend is represented by reduced roles of chronic rheumatic heart disease and congenital heart defects, increased proportion of IE associated with medical care, valve replacement, installation of intracardiac devices, and increased contribution of Staphylococcus spp. and Enterococcus spp. to the IE etiology. Additional visualization methods (fluorodeoxyglucose positron emission tomography with 18F-fludesoxyglucose (18F-FDG PET-CT), labeled white blood cell single-photon emission computed tomography (SPECT), and modernization of the etiological diagnostic algorithm for determining the true pathogen (immunochemistry, polymerase chain reaction, sequencing) also become increasingly important. The COVID-19 pandemic has also adversely contributed to the IE epidemiology. New prospects of treatment have emerged, such as bacteriophages, lysins, oral antibacterial therapy, minimally invasive surgical strategies (percutaneous mechanical aspiration), endovascular mechanical embolectomy. The physicians' compliance with clinical guidelines (CG) is low, which contributes to the high rate of adverse outcomes of IE, while simple adherence to the CG together with more frequent use of surgical treatment doubles survival. Systematic adherence to CG, timely prevention and implementation of the Endocarditis Team into practice play the decisive role in a favorable prognosis of dynamically changing IE. This article presents the authors' own data that confirm the evolutionary trends of current IE.

Healthcare-Associated Infective Endocarditis—Surgical Perspectives

Health-care-associated infective endocarditis (HCA-IE), a disease with a poor prognosis, has become increasingly important. As surgical treatment is frequently required, this review aims to outline surgical perspectives on HCA-IE. We searched PubMed to identify publications from January 1980 to March 2022. Reports were evaluated by the authors against a priori inclusion/exclusion criteria. Studies reporting on surgical treatment of HCA-IE including outcome were selected. Currently, HCA-IE accounts for up to 47% of IE cases. Advanced age, cardiac implants, and comorbidity are important predispositions, and intravascular catheters or frequent vascular access are significant sources of infection. Staphylococci and enterococci are the leading causative microorganisms. Surgery, although frequently indicated, is rejected in 24–69% because of prohibitive risk. In-hospital mortality is significant after surgery (29–50%) but highest in patients rejected for operation (52–83%). Furthermore, the length of hospital stay is prolonged. With aging populations, age-dependent morbidity, increasing use of cardiac implants, and growing healthcare utilization, HCA-IE is anticipated to gain further importance. A better understanding of pathogenesis, clinical profile, and outcomes is paramount. Further research on surgical treatment is needed to provide more comprehensive information for defining the most suitable treatment option, finding the optimal time for surgery, and reducing morbidity and mortality.

Antibacterial and Antifungal Management in Relation to the Clinical Characteristics of Elderly Patients with Infective Endocarditis: A Retrospective Analysis

Infective endocarditis (IE) is increasingly prevalent in the elderly, particularly due to the rising frequency of invasive procedures and intracardiac devices placed on these individuals. Several investigations have highlighted the unique clinical and echocardiographic characteristics, the microorganisms implicated, and the prognosis of IE in the elderly. In addition, the old population seems to be fairly diverse, ranging from healthy individuals with no medical history to patients with many ailments and those who are immobile. Furthermore, the therapy of IE in this group has not been well investigated, and worldwide recommendations do not propose tailoring the treatment approach to the patient’s functional state and comorbid conditions. A multicenter research study was designed as a retrospective study of hospitalized patients with infective endocarditis, aiming to examine the characteristics of elderly patients over 65 years old with infective endocarditis in relation to the antibiotic and antifungal treatments administered, as well as to quantify the incidence of treatment resistance, adverse effects, and mortality in comparison to patients younger than 65. Based on a convenience sampling method, we included in the analysis a total of 78 patients younger than 65 and 131 patients older than 65 years. A total of 140 patients had endocarditis on native valves and 69 patients had endocarditis on prosthetic valves. A significantly higher proportion of elderly patients had signs of heart failure on admission, and the mortality rate was significantly higher in the elderly population. A majority of infections had a vascular cause, followed by dental, maxillo-facial, and ENT interventions. The most common complications of IE were systemic sepsis (48.1% of patients older than 65 years vs. 30.8% in the younger group). The most frequent bacterium involved was Staphylococcus aureus, followed by Streptococcus spp. in a total of more than 50% of all patients. The most commonly used antibiotics were cephalosporins in 33.5% of cases, followed by penicillin in 31.2% and glycopeptides in 28.7%, while Fluconazole was the initial option of treatment for fungal endocarditis in 24.9% of cases. Heart failure at admission (OR = 4.07), the development of septic shock (OR = 6.19), treatment nephrotoxicity (OR = 3.14), severe treatment complications (OR = 4.65), and antibiotic resistance (OR = 3.24) were significant independent risk factors for mortality in the elderly patients. Even though therapeutic management was initiated sooner in the older patients, the associated complications and mortality rate remained significantly greater than those in the patients under 65 years old.

Endocardite Infecciosa: Ainda mais Desafios que Certezas

Após catorze décadas de evolução médica e tecnológica, a endocardite infeciosa continua a desafiar médicos no seu diagnóstico e manejo diário. O aumento da incidência, alterações demográficas (afetando pacientes mais idosos), microbiologia com taxas de infeção por Staphylococcus mais elevadas, com complicações graves ainda frequentes e uma mortalidade substancial tornam a endocardite uma doença muito complexa. Apesar de tudo, a inovação no seu diagnóstico, nomeadamente na área da microbiologia e imagem, e a melhoria nos cuidados intensivos e na cirurgia cardíaca (quanto às técnicas, materiais usados e momento de intervenção) podem ter um impacto no seu prognóstico. Os desafios persistem, incluindo repensar a profilaxia, melhorar os critérios de diagnóstico incluindo a endocardite com culturas negativas e endocardite de prótese valvar, o timing para a intervenção cirúrgica, e sua realização ou não na presença de acidente vascular cerebral isquêmico e em usuários de drogas intravenosas. Uma estratégia combinada na endocardite infeciosa é fundamental, incluindo decisões e protocolos clínicos avançados, um manejo multidisciplinar, organização e políticas de saúde que culminem em melhores resultados para os nossos pacientes.

Epidemiology of infective endocarditis: novel aspects in the twenty-first century

INTRODUCTION

The epidemiology of infective endocarditis (IE) in this millennium has changed with emergence of new risk factors and reemergence of others. This, coupled with modifications in national guidelines in the setting of a pandemic, prompted an address of the topic.

AREAS COVERED

Our goal is to provide a contemporary review of IE epidemiology considering changing incidence of rheumatic heart disease (RHD), cardiac device implantation, and injection drug use (IDU), with SARS-CoV-2 pandemic as the backdrop.

METHODS

PubMed and Google Scholar were used to identify studies of interest.

EXPERT OPINION

Our experience over the past two decades verifies the notion that there is not one 'textbook' profile of IE. Multiple factors have dramatically impacted IE epidemiology, and these factors differ, based, in part on geography. RHD has declined in many areas of the world, whereas implanted cardiovascular devices-related IE has grown exponentially. Perhaps the most influential, at least in areas of the United States, is injection drug use complicating the opioid epidemic. Healthy younger individuals contracting a potentially life-threatening infection has been tragic. In the past year, epidemiological changes due to the COVID-19 pandemic have also occurred. No doubt, changes will characterize IE in the future and serial review of the topic is warranted.

Nosocomial Native Valve Endocarditis due to Methicillin-Susceptible Staphylococcus aureus in a Patient with Psoriatic Arthritis

Nosocomial infective endocarditis is a relatively rare, but critical disease. A Japanese man in his 80s with psoriatic arthritis that was being treated with prednisolone was admitted for dyspnea. The first diagnosis was healthcare-associated pneumonia, and piperacillin/tazobactam was started. The patient's blood culture was negative at the time of admission. During the treatment, acute kidney injury occurred due to the use of antibiotics. Hemodialysis was performed via a central venous catheter in the internal jugular vein. After treatment of pneumonia, the patient experienced a sudden onset of fever accompanied by a loss of consciousness. Blood cultures from the peripheral vein and the central venous catheter were positive for methicillin-susceptible Staphylococcus aureus. A transthoracic echocardiography revealed stringy strands of vegetation attached to the native mitral valve. Magnetic resonance imagings also showed a shower of emboli to the brain. Ceftriaxone and vancomycin were administered; however, the patient died following a massive cerebral infarction. Instances of in-hospital mortality from nosocomial endocarditis are higher than the rates of community-acquired endocarditis. Clinicians should pay close attention to risk factors for nosocomial infective endocarditis. These risk factors include long-term indwelling vascular devices, psoriatic arthritis and corticosteroid therapy.

Clinical Features and Outcome of Infective Endocarditis in a University Hospital in Romania

Background and Objectives: Characterization of patients with endocarditis regarding demographic, clinical, biological and imagistic data, blood culture results and possible correlation between different etiologic factors and host status characteristics. Material and methods: This is a retrospective observational descriptive study conducted on patients older than 18 years admitted in the past 10 years, in the Cardiology Clinic of the Clinical County Emergency Hospital Oradea Romania, with clinical suspicion of bacterial endocarditis. Demographic data, clinical, paraclinical investigations and outcome were registered and analyzed. Results: 92 patients with definite infective endocarditis (IE) according to modified Duke criteria were included. The mean age of patients was 63.80 ± 13.45 years. A percent of 32.6% had health care associated invasive procedure performed in the 6 months before diagnosis of endocarditis. Charlson's comorbidity index number was 3.53 ± 2.029. Most common clinical symptoms and signs were: shortness of breath, cardiac murmur, fever. Sixty-six patients had native valve endocarditis, 26 patients had prosthetic valve endocarditis and one patient was with congenital heart disease. Blood cultures were positive in 61 patients. Among positive culture patient's staphylococcus group was the most frequently involved: Staphylococcus aureus (19.6%) and coagulase negative Staphylococcus (18.5%). Most frequent complications were heart failure, acute renal failure and embolic events. Conclusions: Staphylococcus aureus IE was associated with the presence of large vegetations, prosthetic valve endocarditis and intracardiac abscess. Coagulase negative Staphylococcus (CoNS) infection was associated with prosthetic valve dysfunction. Streptococcus gallolyticus etiology correlated with ischemic embolic stroke and the presence of large vegetations. Cardiovascular surgery was recommended in 67.4% of patients but was performed only on half of them. In hospital death occurred in 33.7% of patients and independent predictors of mortality were congestive heart failure and septic shock.

Hospital-acquired infective endocarditis during Covid-19 pandemic

BACKGROUND

The COVID pandemic has had a major impact on healthcare in hospitals, including the diagnosis and treatment of infections. Hospital-acquired infective endocarditis (HAIE) is a severe complication of medical procedures that has shown a progressive increase in recent years.

OBJECTIVES

To determine whether the incidence of HAIE during the first two months of the epidemic (March-April 2020) was higher than previously observed and to describe the clinical characteristics of these cases. The probability of the studied event (HAIE) during the study period was calculated by Poisson distribution.

RESULTS

Four cases of HAIE were diagnosed in our institution during the study period. The incidence of HAIE during the study period was 2/patient-month and 0.3/patient-month during the same calender months in the previous 5 years (p=0.033). Two cases presented during admission for COVID-19 with pulmonary involvement treated with methylprednisolone and tocilizumab. The other two cases were admitted to the hospital during the epidemic. All cases underwent central venous and urinary catheterization during admission. The etiology of HAIE was Enterococcus faecalis (2 cases), Staphylococcus aureus and Candida albicans (one case each). A source of infection was identified in three cases (central venous catheter, peripheral venous catheter, sternal wound infection, respectively). One patient was operated on. Two patients died during hospital admission.

CONCLUSIONS

The incidence of HAIE during COVID-19 pandemic in our institution was higher than usual. In order to reduce the risk of this serious infection, optimal catheter care and early treatment of every local infection should be prioritized during coronavirus outbreaks.

Three Separate Clinical Entities of Infective Endocarditis-A Population-Based Study From Southern Finland 2013-2017

Background

Health care–associated infective endocarditis (HAIE) and intravenous drug use–related IE (IDUIE) have emerged as major groups in infective endocarditis (IE). We studied their role and clinical picture in a population-based survey.

Methods

A population-based retrospective study including all adult patients diagnosed with definite or possible IE in Southern Finland in 2013–2017. IE episodes were classified according to the mode of acquisition into 3 groups: community-acquired IE (CAIE), HAIE, and IDUIE.

Results

Total of 313 episodes arising from 291 patients were included. Incidence of IE was 6.48/100 000 person-years. CAIE accounted for 38%, HAIE 31%, and IDUIE 31% of IE episodes. Patients in the IDUIE group were younger, and they more frequently had right-sided IE (56.7% vs 5.0%; P < .001) and S. aureus as etiology (74.2% vs 17.6%; P < .001) compared with the CAIE group. In-hospital (15.1% vs 9.3%; P = .200) and cumulative 1-year case fatality rates (18.5% vs 17.5%; P = .855) were similar in CAIE and IDUIE. Patients with HAIE had more comorbidities, prosthetic valve involvement (29.9% vs 10.9%; P = .001), enterococcal etiology (20.6% vs 5.9%; P = .002), and higher in-hospital (27.8% vs 15.1%; P = .024) and cumulative 1-year case fatality rates (43.3% vs 18.5%; P < .001) than patients with CAIE. Staphylococcus aureus caused one-fifth of IE episodes in both groups.

Conclusions

Our study indicates that in areas where injection drug use is common IDUIE should be regarded as a major risk group for IE, along with HAIE, and not seen as part of CAIE. Three different risk groups, CAIE, HAIE, and IDUIE, with variable characteristics and outcome should be recognized in IE.

Comparison Between Healthcare-Associated and Community-Acquired Infective Endocarditis at Tertiary Care Hospitals in Japan

BACKGROUND

Healthcare-associated infective endocarditis (HAIE) has become increasingly recognized worldwide because the underlying patient conditions are completely different from those of community-acquired infective endocarditis (CIE). However, data on HAIE in the Japanese population is lacking. We sought to clarify the patient characteristics and prognosis of HAIE in a Japanese population.Methods and Results:A retrospective study was conducted in 158 patients who were diagnosed with infective endocarditis, 53 of whom (33.5%) were classified as HAIE. Compared with patients with CIE, those with HAIE were older (median age 72 vs. 61 years; P=0.0002) and received surgical treatment less frequently (41.5% vs. 62.9%; P=0.01). Regarding causative microorganisms, staphylococci,including methicillin-resistant pathogens, were more common in patients with HAIE (32.1% vs. 14.3%; P=0.01). Patients with HAIE had higher in-hospital mortality (32.1% vs. 4.8%; P<0.0001) and Kaplan-Meier analysis showed worse prognosis for patients with HAIE than CIE (P<0.0001, log-rank test). On multivariate Cox analysis, HAIE (hazard ratio 3.26; 95% confidence interval 1.49-7.14), age ≥60 years, surgical treatment, stroke, and heart failure were independently associated with mortality.

CONCLUSIONS

HAIE has different clinical characteristics and causative microorganisms, as well as worse prognosis, than CIE. Preventive strategies, and the prompt and appropriate identification of HAIE may improve the outcome of infective endocarditis.

Trends in Hospitalization for Infective Endocarditis as a Reason for Admission or a Secondary Diagnosis

We postulate that the trends for infective endocarditis (IE) are different for patients admitted for this condition compared with those admitted for a different reason with IE as a secondary diagnosis. Using the Myocardial Infarction Data Acquisition System (MIDAS) database, we analyzed 21,443 records of patients hospitalized with diagnosis of IE from 1994 to 2015. There were 9,191 patients hospitalized with IE as the primary diagnosis, and 12,252 patients with IE as a secondary diagnosis. Piecewise linear models were used to detect changes in trends. A bootstrap method was used to assess the statistical significance of the slopes and break point of each model. Differences in co-morbidities and microbiological patterns were analyzed. Trend analysis showed a significant decrease in IE as the primary diagnosis starting in the year 2004 (p <0.01). Hospitalizations with IE as a secondary diagnosis showed a linear increase in incidence (p <0.001), without any change points. In primary diagnosis IE, the proportion of streptococci as a causative microorganism was higher compared with staphylococci (p <0.001). On the contrary, in secondary diagnosis IE, the proportion of staphylococci was higher than streptococci (p <0.001). The proportion of gram-negative and other organism IE was similar in both groups. In conclusion, this study showed 2 divergent temporal trends in hospitalizations for IE as a primary or secondary diagnosis starting in 2004. The profile of the microorganisms reveals a steady higher proportion of staphylococcal infection in secondary diagnosis IE compared with streptococcal infection. Different strategies are needed for the prevention of IE.

Epidemiological and clinical profile of infective endocarditis at a Brazilian tertiary care center: an eight-year prospective study

INTRODUCTION

Infective endocarditis (IE) is a systemic infectious disease requiring a multidisciplinary team for treatment. This study presents the epidemiological and clinical data of 73 cases of IE in Rio de Janeiro, Brazil.

METHODS

This observational prospective cohort study of endocarditis patients during an eight-year study period described 73 episodes of IE in 70 patients (three had IE twice). Community-associated (CAIE) and healthcare-acquired infective endocarditis (HAIE) were diagnosed according to the modified Duke criteria. The collected data included demographic, epidemiologic, and clinical characteristics, including results of blood cultures, echocardiographic findings, surgical interventions, and outcome.

RESULTS

Analysis of data from the eight-year study period and 73 cases (70 patients) of IE showed a mean age of 46 years (SD=2.5 years; 1-84 years) and that 65.7% were male patients. The prevalence of CAIE and HAIE was 32.9% and 67.1%, respectively. Staphylococcus aureus (30.1%), Enterococcus spp. (19.1%), and Streptococcus spp. (15.0%) were the prevalent microorganisms. The relevant signals and symptoms were fever (97.2%; mean 38.6 + 0.05°C) and heart murmur (87.6%). Vegetations were observed in the mitral (41.1%) and aortic (27.4%) valves. The mortality rate of the cases was 47.9%.

CONCLUSIONS

In multivariate analysis, chronic renal failure (relative risk [RR]= 1.60; 95% confidence interval [CI] 1.01-2.55), septic shock (RR= 2.19; 95% CI 1.499-3.22), and age over 60 years (RR= 2.28; 95% CI 1.44-3.59) were indirectly associated with in-hospital mortality. The best prognosis was related to the performance of cardiovascular surgery (hazard ratio [HR]= 0.51; 95% CI 0.26-0.99).

Risk factors for poor prognosis in nosocomial infective endocarditis

BACKGROUND/AIMS

The aim of our study was to compare the characteristics of nosocomial infective endocarditis (NIE) with community-acquired infective endocarditis (CIE) and to determine independent risk factors for in-hospital death.

METHODS

We retrospectively reviewed the medical records of 560 patients diagnosed with infective endocarditis. NIE was defined by a diagnosis made > 72 hours after hospital admission or within 2 months of hospital discharge.

RESULTS

Among the 560 cases reviewed, 121 were classified as NIE. Compared with patients with CIE, patients with NIE were older (mean ± SD, 51.30±18.01 vs. 59.76±14.87, p < 0.001). The in-hospital death rate of the NIE group was much higher than that of the CIE group (27.3% vs. 5.9%, p < 0.001). More patients with NIE had central intravenous catheters, and were undergoing hemodialysis (p < 0.001). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common causal microorganism of NIE, and MRSA (p < 0.001) and fungus (p = 0.002) were more common in NIE compared with CIE. On multiple analysis, age, liver cirrhosis, cancer chemotherapy, central intravenous catheter, hemodialysis, and genitourinary tract manipulation were independent clinical risk factors for NIE. Among the patients with NIE, 33 died during their hospital admission. The independent risk factors for in-hospital death were older age (adjusted odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01 to 1.07; p = 0.037) and chemotherapy for malignancy (adjusted OR, 3.89; 95% CI, 1.18 to 12.87; p = 0.026).

CONCLUSIONS

Because of the considerable incidence of NIE and its poor prognosis, we should pay attention to early diagnosis and active management of NIE, especially for older patients and patients receiving chemotherapy.

Endocarditis due to Rhodotorula mucilaginosa in a kidney transplanted patient: case report and review of medical literature

Introduction. Endocarditis caused by yeasts is currently an emerging cause of infective endocarditis and, when accompanied byfever of unknown origin, is more severe since interferes with proper diagnosis and endocarditis treatment.

Case presentation. The Rio de Janeiro Infective Endocarditis Study Group reports a case of infectious endocarditis (IE) with negative blood cultures in a 45-year-old white female resident in Rio de Janeiro, Brazil, previously submitted to kidney transplantation. After diagnosis and intervention, the valve culture revealed Rhodotorula mucilaginosa. The clinical aspects and overview of endocarditis caused by Rhodotorula spp. demonstrated that R. muscilaginosa have been isolated from the last IE cases from kidney transplanted patients.

Conclusion. Though most of the patients (in literature) recovered well from endocarditis caused by Rhodotorula spp., physicians must be aware for diagnosis of fungemia and fungal treatment in kidney transplanted patients suffering of fever of unknown origin in the modern immunosuppressive treatment.

The role of biofilms in persistent infections and factors involved in ica-independent biofilm development and gene regulation in Staphylococcus aureus

Staphylococcus aureus biofilms represent a unique micro-environment that directly contribute to the bacterial fitness within hospital settings. The accumulation of this structure on implanted medical devices has frequently caused the development of persistent and chronic S. aureus-associated infections, which represent an important social and economic burden worldwide. ica-independent biofilms are composed of an assortment of bacterial products and modulated by a multifaceted and overlapping regulatory network; therefore, biofilm composition can vary among S. aureus strains. In the microniches formed by biofilms-produced by a number of bacterial species and composed by different structural components-drug refractory cell subpopulations with distinct physiological characteristics can emerge and result in therapeutic failures in patients with recalcitrant bacterial infections. In this review, we highlight the importance of biofilms in the development of persistence and chronicity in some S. aureus diseases, the main molecules associated with ica-independent biofilm development and the regulatory mechanisms that modulate ica-independent biofilm production, accumulation, and dispersion.

[Left-sided native valve infective endocarditis: Influence of age and the presence of underlying heart disease]

INTRODUCTION AND OBJECTIVES

Left-sided native valve infective endocarditis (LNVIE) epidemiology has been modified as a result of the increase in average age. The aim of our study is to analyze the influence of age and the presence of predisposing heart disease in the prognosis of these patients.

METHODS

We analyzed a series of 257 cases of LNVIE depending on their age (greater than or equal to 70 years old), both in the overall series and in the subgroup of patients without predisposing heart disease.

RESULTS

Mean age was 54.6 (18.6) years. There was an increase in the percentage of cases of older patients between 1987-2000 and 2001-2014 (9.8 vs. 34.8%, P<.001). These patients present higher prevalence of degenerative valves (50 vs. 22.8%) or not predisposing heart disease (50 vs. 39.9%), P<.001, health-care associated episodes (41.8 vs. 23.6%, P=.016), lower rate of surgery (43.7 vs. 63.8%, P=.005) and higher in-hospital mortality (39.1 vs. 20.7%, P=.003), with no differences in comorbidities. Older patients who did not have predisposing heart disease also suffered higher in-hospital mortality (47 vs. 22%, P=.01). Age greater than or equal to 70 years old is an independent predictor of mortality in patients with LNVIE (OR 2.53, 95% CI 1.24-5.15, P=.011), as in those without previous heart disease (OR 3.98, 95% CI 1.49-10.62, P=.006).

CONCLUSIONS

Patients of age greater than or equal to 70 years old and who suffer an LNVIE are becoming more frequent and have a worse prognosis with a lower rate of surgery and higher rates of in-hospital mortality.

Efficacy of ceftaroline versus vancomycin in an experimental foreign-body and systemic infection model caused by biofilm-producing methicillin-resistant Staphylococcus epidermidis

In this study, the efficacy of ceftaroline versus vancomycin against biofilm-producing methicillin-resistant Staphylococcus epidermidis (MRSE) in a murine model of foreign-body and systemic infection was compared. Two bacteraemic biofilm-producing MRSE strains were used (SE284 and SE385). The minimum inhibitory concentrations (MICs) for strains SE284 and SE385, were, respectively, 0.25 mg/L and 0.5 mg/L for ceftaroline and 4 mg/L and 2 mg/L for vancomycin. The in vitro bactericidal activities of ceftaroline and vancomycin were evaluated using time-kill curves. A foreign-body and systemic infection model in neutropenic female C57BL/6 mice was used to ascertain in vivo efficacy. Animals were randomly allocated into three groups (n = 15) without treatment (controls) or treated with ceftaroline 50 mg/kg every 8 h or vancomycin 110 mg/kg every 6 h. In vitro, ceftaroline showed concentration-dependent bactericidal activity, whilst vancomycin presented time-dependent activity. In the experimental in vivo model, ceftaroline and vancomycin decreased the liver and catheter bacterial concentrations (P <0.05) and increased survival (P <0.05) for both strains. In conclusion, ceftaroline is as effective as vancomycin in the treatment of experimental foreign-body and systemic infection caused by biofilm-producing MRSE.

Non-nosocomial healthcare-associated left-sided Pseudomonas aeruginosa endocarditis: a case report and literature review

Background

With the development of invasive medical procedures, an increasing number of healthcare-associated infective endocarditis cases have been reported. In particular, non-nosocomial healthcare-associated infective endocarditis in outpatients with recent medical intervention has been increasingly identified.

Case presentation

A 66-year-old man with diabetes mellitus and a recent history of intermittent urethral self-catheterization was admitted due to a high fever. Repeated blood cultures identified Pseudomonas aeruginosa, and transesophageal echocardiography uncovered a new-onset severe aortic regurgitation along with a vegetative valvular structure. The patient underwent emergency aortic valve replacement surgery and was successfully treated with 6 weeks of high-dose meropenem and tobramycin. Historically, most cases of P. aeruginosa endocarditis have occurred in the right side of the heart and in outpatients with a history of intravenous drug abuse. In the case presented, the repeated manipulations of the urethra may have triggered the infection. Our literature review for left-sided P. aeruginosa endocarditis showed that non-nosocomial infection accounted for nearly half of the cases and resulted in fatal outcomes as often as nosocomial cases. A combination therapy with anti-pseudomonal beta-lactams or carbapenems and aminoglycosides may be the preferable treatment. Medical treatment alone may be effective, and surgical treatment should be carefully considered.

Conclusions

We presented a rare case of native aortic valve endocarditis caused by P. aeruginosa. This case illustrates the importance of identifying the causative pathogen(s), especially for outpatients with a recent history of medical procedures.

The causative agents in infective endocarditis: a systematic review comprising 33,214 cases

Infective endocarditis (IE) incidence remains high with considerable fatality rates; guidelines for prophylaxis against IE are currently under review in some settings which highlights the importance of maintaining up-to-date epidemiological estimates about the most common microbial causes. The objective of this systematic review, following PRISMA guidelines, was to identify the most common microbial causes of IE in recent years. Medline was searched from January 1, 2003 to March 31, 2013 for all articles containing the term "infective endocarditis". All relevant studies reporting diagnostic results were included. Special patient subpopulations were assessed separately. A total of 105 studies were included, from 36 countries, with available data on a total of 33,214 cases. Staphylococcus aureus was found to be the most common microorganism, being the most frequent in 54.3 % of studies (N = 57) (and in 55.4 % of studies using Duke's criteria for diagnosis [N = 51]). Viridans group streptococci (VGS), coagulase-negative staphylococci (CoNS), Enterococcus spp and Streptococcus bovis were among the most common causes. S. aureus was the most common pathogen in almost all population subgroups; however, this was not the case in patients with implantable devices, prosthetic valves, or immunocompromised non-HIV, as well as in the sub-group from Asia, emphasizing that a global one-size-fits-all approach to the management of suspected IE is not appropriate. This review provides an evidence-based map of the most common causative agents of IE, highlighting S. aureus as the leading cause in the 21st century. The changing epidemiology of IE in some patient sub-groups in the last decade and the very high number of microbiologically undiagnosed cases (26.6 %) suggest the need to revisit IE prophylaxis and diagnostic strategies.

A comparison of different antibiotic regimens for the treatment of infective endocarditis

BACKGROUND

Infective endocarditis is a microbial infection of the endocardial surface of the heart. Antibiotics are the cornerstone of treatment, but their use is not standardised, due to the differences in presentation, populations affected and the wide variety of micro-organisms that can be responsible.

OBJECTIVES

To assess the existing evidence about the clinical benefits and harms of different antibiotics regimens used to treat people with infective endocarditis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE Classic and EMBASE, LILACS, CINAHL and the Conference Proceedings Citation Index on 30 April 2015. We also searched three trials registers and handsearched the reference lists of included papers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of antibiotic regimens for treating possible infective endocarditis diagnosed according to modified Duke's criteria. We considered all-cause mortality, cure rates and adverse events as the primary outcomes. We excluded people with possible infective endocarditis and pregnant women.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We constructed 'Summary of findings' tables and used GRADE methodology to assess the quality of studies. We described the included studies narratively.

MAIN RESULTS

Four small randomised controlled trials involving 728 allocated/224 analysed participants met our inclusion criteria. These trials had a high risk of bias. Drug companies sponsored two of the trials. We were unable to pool the data due to the heterogeneity in outcome definitions and the different antibiotics used.The included trials compared the following antibiotic schedules. The first trial compared quinolone (levofloxacin) plus standard treatment (anti-staphylococcal penicillin (cloxacillin or dicloxacillin), aminoglycoside (tobramycin or netilmicin) and rifampicin) versus standard treatment alone reporting uncertain effects on all-cause mortality (8/31 (26%) with levofloxacin plus standard treatment versus 9/39 (23%) with standard treatment alone; RR 1.12, 95% CI 0.49 to 2.56, very low quality evidence). The second trial compared daptomycin versus low-dose gentamicin plus an anti-staphylococcal penicillin (nafcillin, oxacillin or flucloxacillin) or vancomycin. This showed uncertain effects in terms of cure rates (9/28 (32.1%) with daptomycin versus 9/25 (36%) with low-dose gentamicin plus anti-staphylococcal penicillin or vancomycin, RR 0.89 95% CI 0.42 to 1.89; very low quality evidence). The third trial compared cloxacillin plus gentamicin with a glycopeptide (vancomycin or teicoplanin) plus gentamicin. In participants receiving gentamycin plus glycopeptide only 13/23 (56%) were cured versus 11/11 (100%) receiving cloxacillin plus gentamicin (RR 0.59, 95% CI 0.40 to 0.85; very low quality evidence). The fourth trial compared ceftriaxone plus gentamicin versus ceftriaxone alone and found no conclusive differences in terms of cure (15/34 (44%) with ceftriaxone plus gentamicin versus 21/33 (64%) with ceftriaxone alone, RR 0.69, 95% CI 0.44 to 1.10; very low quality evidence).The trials reported adverse events, need for cardiac surgical interventions, uncontrolled infection and relapse of endocarditis and found no conclusive differences between comparison groups (very low quality evidence). No trials assessed septic emboli or quality of life.

AUTHORS' CONCLUSIONS

Limited and very low quality evidence suggested that there were no conclusive differences between antibiotic regimens in terms of cure rates or other relevant clinical outcomes. However, because of the very low quality evidence, this needs confirmation. The conclusion of this Cochrane review was based on randomised controlled trials with high risk of bias. Accordingly, current evidence does not support or reject any regimen of antibiotic therapy for treatment of infective endocarditis.

Switch to oral antibiotics in the treatment of infective endocarditis is not associated with increased risk of mortality in non-severely ill patients

Although many international guidelines exist for the management of infective endocarditis (IE), recommendations are lacking on the opportunity of switching antibiotics from the intravenous (IV) to oral route during treatment. We present a cohort study of 426 cases of IE over a period of 13 years (2000-2012), including 369 cases of definite IE according to the Duke criteria. Predictors of mortality were identified using the Cox proportional hazard analysis. The median (range) age at diagnosis was 64.5 (7-98) years. One hundred six patients (25%) had healthcare-associated IE. Oral streptococci (n = 99, 23%) and Staphylococcus aureus (n = 81, 19%) were the predominant microorganisms. Ninety-two patients (22%) died during follow-up. After an initial phase of IV antibiotherapy, 214 patients (50%) were switched to oral route a median (range) of 21 (0-70) days after diagnosis of IE. Patients in the oral group had fewer comorbidities, and criteria of severity at inclusion and were less frequently infected by S. aureus. Oral antibiotics were amoxicillin alone in 109 cases or a combination therapy of clindamycin, fluoroquinolone, rifampicin and/or amoxicillin in 46 cases, according to the susceptibility of the microorganisms. In the multivariate analysis, a switch to oral route was not associated with an increased risk of mortality. During follow-up, only two relapses and four reinfections were observed in the oral group (compared to nine and eight in the IV group, respectively). In this study, switching to oral administration was not associated with an increased risk of relapse or reinfection. These promising results need to be confirmed by prospective studies.

Infective endocarditis: Clinical presentation, etiology, and early predictors of in-hospital case fatality

OBJECTIVE

We aimed to assess the clinical presentation, microbial etiology and outcome of patients presenting with infective endocarditis (IE).

PATIENTS AND METHODS

We conducted a four-year retrospective study including all patients presenting with IE.

RESULTS

We included 121 patients in the study. The median age was 74.8years. Most patients had native valve IE (57%). Staphylococcus aureus accounted for 24.8% of all IE. Surgery was indicated for 70 patients (57.9%) but actually performed in only 55 (44.7%). Factors associated with surgery were younger age (P=0.002) and prosthetic valve IE (P=0.001). Risk factors associated with in-hospital mortality were diabetes mellitus (OR=3.17), chronic renal insufficiency (OR=6.62), and surgical indication (OR=3.49). Mortality of patients who underwent surgery was one sixth of that of patients with surgical indication who did not have the surgery (P<0.001).

Left-sided infective endocarditis in patients with liver cirrhosis

OBJECTIVE

To evaluate the course of left-sided infective endocarditis (LsIE) in patients with liver cirrhosis (LC) analyzing its influence on mortality and the impact of surgery.

METHODS

Prospective cohort study, conducted from 1984 to 2013 in 26 Spanish hospitals.

RESULTS

A total of 3.136 patients with LsIE were enrolled and 308 had LC: 151 Child-Pugh A, 103 B, 34 C and 20 were excluded because of unknown stage. Mortality was significantly higher in the patients with LsIE and LC (42.5% vs. 28.4%; p < 0.01) and this condition was in general an independent worse factor for outcome (HR 1.51, 95% CI: 1.23-1.85; p < 0.001). However, patients in stage A had similar mortality to patients without cirrhosis (31.8% vs. 28.4% p = NS) and in this stage heart surgery had a protective effect (28% in operated patients vs. 60% in non-operated when it was indicated). Mortality was significantly higher in stages B (52.4%) and C (52.9%) and the prognosis was better for patients in stage B who underwent surgery immediately (mortality 50%) compared to those where surgery was delayed (58%) or not performed (74%). Only one patient in stage C underwent surgery.

CONCLUSIONS

Patients with liver cirrhosis and infective endocarditis have a poorer prognosis only in stages B and C. Early surgery must be performed in stages A and although in selected patients in stage B when indicated.

Healthcare-associated infective endocarditis of the pulmonary valve

We report a case of a 66-year-old man with known ischaemic heart disease, diabetes mellitus and stage 4 kidney disease who was admitted to our tertiary centre with shortness of breath and atrial flutter. Transoesophageal echocardiography (TOE) was without suspicion of endocarditis. During hospitalisation, the patient suffered a nosocomial infection in a peripheral vascular catheter caused by Staphylococcus aureus. TOE after positive blood cultures revealed a new vegetation on the pulmonary valve that resolved after antibiotic treatment.

Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases

OBJECTIVE

In order to define the current characteristics of infective endocarditis (IE) in Turkey, we evaluated IE cases over a 14-year period in a tertiary referral hospital.

METHODS

All adult patients who were hospitalized in our hospital with a diagnosis of IE between 2000 and 2013 were included in the study. Modified Duke criteria were used for diagnosis. The Chi-square test, Student's t-test, Mann-Whitney U-test, Cox and logistic regression analysis were used for the statistical analysis.

RESULTS

There were 325 IE cases during the study period. The mean age of the patients was 47 years. Causative microorganisms were identified in 253 patients (77.8%) and included staphylococci (36%), streptococci (19%), enterococci (7%), and Brucella spp (5%). A streptococcal aetiology was associated with younger age (<40 years) (p=0.001), underlying chronic rheumatic heart disease (CRHD) (odds ratio (OR) 3.89) or a congenital heart defect (OR 4.04), community acquisition (OR 17.93), and native valve (OR 3.68). A staphylococcal aetiology was associated with healthcare acquisition (OR 2.26) or pacemaker lead-associated endocarditis (OR 6.63) and an admission creatinine level of >1.2mg/dl (OR 2.15). Older age (>50 year) (OR 3.93), patients with perivalvular abscess (OR 9.18), being on dialysis (OR 6.22), and late prosthetic valve endocarditis (OR 3.15) were independent risk factors for enterococcal IE. Independent risk factors for mortality in IE cases were the following: being on dialysis (hazard ratio (HR) 4.13), presence of coronary artery heart disease (HR 2.09), central nervous system emboli (HR 2.33), and congestive heart failure (HR 2.15). Higher haemoglobin (HR 0.87) and platelet (HR 0.996) levels and surgical interventions for IE (HR 0. 33) were found to be protective factors against mortality.

CONCLUSIONS

In Turkey, IE occurs in relatively young patients and Brucella spp should always be taken into consideration as a cause of this infection. We should first consider streptococci as the causative agents of IE in young patients, those with CRHD or congenital heart valve disease, and cases of community-acquired IE. Staphylococci should be considered first in the case of pacemaker lead IE, when there are high levels of creatinine, and in cases of healthcare-associated IE. Enterococci could be the most probable causative agent of IE particularly in patients aged >50 years, those on dialysis, those with late prosthetic valve IE, and those with a perivalvular abscess. The early diagnosis and treatment of IE before complications develop is crucial because the mortality rate is high among cases with serious complications. The prevention of bacteraemia with the measures available among chronic haemodialysis patients should be a priority because of the higher mortality rate of subsequent IE among this group of patients.

Health Care-Associated Infective Endocarditis: a Growing Entity that Can Be Prevented

Infective endocarditis (IE) continues to be a serious disease with a poor prognosis and high mortality. Neither incidence rates nor mortality have decreased in recent decades. Because of this, it is important to prevent IE in patients at risk. In the past, prevention of IE has focused on antimicrobial prophylaxis, mainly for dental procedures. However, recent major changes in epidemiology, the most significant being the growing frequency and high mortality rate of health care-associated valve endocarditis (HAIE), mean that preventive strategies against IE must also change. Since intravascular catheters are the most common source of bacteremia among patients with HAIE, significant efforts must be made to minimize the risk of catheter-related bloodstream infections. Measures for preventing the infection of prosthetic valves and cardiac implantable devices at the time of implantation also need to be implemented.

Infective Endocarditis

Infective endocarditis (IE) is a noncontagious infection of the endocardium and heart valves. The epidemiology of IE has shifted recently with an increase in health care-associated IE. Infective endocarditis requiring intensive care unit stay is increasing, and nosocomial IE is frequently responsible. Diagnosis of IE requires multiple clinical data points encompassing history and physical examination, microbiology, and cardiac imaging as no one test is sufficiently sensitive or specific. The modified Duke criteria algorithm is the standard of care in the clinical diagnosis of IE. Complications from IE are common, particularly so in the critical care setting, and include congestive heart failure, embolism, septic shock, invasive infection, prosthetic valve dehiscence, heart block, and mycotic aneurysm. A multidisciplinary care team of infectious disease, cardiology, and cardiac surgery physicians is recommended to reduce complications. Intravenous antibiotics are first-line therapy with cardiac surgery being reserved for certain complications of IE and/or for clinical situations in which there is a high risk of complications. Timing of surgery for IE remains controversial and depends on a variety of clinical factors.

Infective endocarditis due to multidrug resistant gram-negative bacilli: single centre experience over 5 years

BACKGROUND

Infective endocarditis (IE) due to gram-negative (GN) bacilli is uncommon. Although multi- and extensively-drug resistant (MDR/XDR) GN infections are emerging, very few data are available on IE due to these microrganisms.

METHODS

In this study, we describe the clinical characteristics, course and outcome of five contemporary, definite, MDR/XDR GNIE cases seen at our centre.

RESULTS

All patients had been admitted to a hospital during the 6months before IE onset, 2 were on hemodialysis and 3 on intravenous medications. Three of the 5 cases were hospital-acquired. Intracardiac prosthetic devices were present in all cases (3 central venous lines, 2 prosthetic heart valves, 2 pacemakers). Mean Charlson comorbidity index was 5.8. Causative pathogens were XDR Pseudomonas aeruginosa (2 cases), XDR Acinetobacter baumannii, MDR Burkolderia cepacia and MDR Escherichia coli (1 case each). Concomitant pathogens with a MDR/XDR phenotype were isolated in 4 patients. Both valves and intracardiac devices and left and right sides of the heart were involved. The rate of complications was high. Antibiotic treatment hinged on the use of colistin, a carbapenem or both. Cardiovascular surgical procedures were performed in 3 patients. Despite aggressive therapeutic regimens, outcomes were poor. Clearance of bacteremia was obtained in 3 patients, in-hospital death occurred in 3 patients, only 1 patient survived during follow up.

CONCLUSIONS

MDR/XDR GN are emerging as a cause of IE in carriers of intracardiac prostheses with extensive healthcare contacts and multiple comorbidities. Resistant GNIE has a complicated course and shows a dismal prognosis.

Infective endocarditis in Rio de Janeiro, Brazil: a 5-year experience at two teaching hospitals

INTRODUCTION

Despite the recent advances in diagnosis and treatment, mortality rates due to infective endocarditis (IE) remain high if not aggressively treated with antibiotics, whether or not associated with surgery. Data on the prevalence, epidemiology and etiology of IE from developing countries remain scarce. The aim of this observational, prospective cohort study was to report a 5-year experience of IE at two teaching hospitals in Rio de Janeiro, Brazil.

MATERIAL AND METHODS

Demographical, anamnestic and microbiological characteristics of 71 IE patients were evaluated during the period of January 2009 to March 2013.

RESULTS

The mean age of the IE patients was 49.8 ± 2.4 years, of which 41 (57.7%) were males. The median time between the onset of symptoms and diagnosis of IE was 35.8 ± 4.8 days. A total of 31 (43.6%) cases of community-acquired infective endocarditis (CAIE) and 40 (56.3%) cases of healthcare-acquired infective endocarditis (HAIE) were observed. Staphylococcus aureus (30%) was the predominant cause of IE. Streptococcus spp. (45.1 %) was the predominant cause of the CAIE while S. aureus (32.5%) and Enterococcus spp. (27.2 %) were the main etiological agents of HAIE. For 64 (90.1 %) patients with native valve endocarditis, the mitral valve was the most commonly affected (48.3%). The main source of IE in this cohort was intravascular catheter. The tricuspid valve and renal chronic insufficiency were more frequent in patients with HAIE than CAIE (p = 0.001). The risk factors associated with in-hospital mortality rate (46.4%) in IE patients were: age over 45 (OR 3.4; 95% CI 1.03-11.24; p = 0.04) and chronic renal insufficiency (OR 38.3; 95% CI 3.2-449.4; p = 0.004).

CONCLUSIONS

At two main teaching hospitals in Brazil, Streptococcus spp. was the principal pathogen of CAIE while S. aureus and Enterococcus spp. were the most frequent causes of HAIE. IE remains a serious disease associated with high in-hospital mortality rate (46.6%); especially, in individuals over 45 years of age and with renal failure. Data suggest that early surgery may improve the outcome of IE patients.

Infective endocarditis in New Zealand children 1994-2012

BACKGROUND

New Zealand is a developed country with high incidence of bacterial infections and postinfectious sequelae including rheumatic heart disease. We sought to describe the clinical and microbiology features of children with infective endocarditis (IE) between 1994 and 2012.

METHODS

Retrospective review of patients <16 years identified from hospital records.

RESULTS

In total 85 episodes occurred in 82 children and 68 (80%) were classified as Definite IE and 17 as Possible IE according to modified Duke criteria. From Pacific Island countries, 13 cases were referred. There were 72 children who originated in New Zealand, of whom 52% were either indigenous New Zealand Maori or Pacific migrants. The median age at diagnosis was 7 (0-15) years. Of the 85 cases, 51 (60%) had congenital heart disease 10 children with rheumatic heart disease developed IE. Of the 85 cases, 35 (41%) met our criteria for healthcare-associated IE. 39/85 underwent surgery for IE. As direct result of IE, 4 (4.7%) children died and 9% of survivors had neurologic sequelae. Attributable in-hospital mortality was 4.7%. Staphylococcus aureus was the most common organism, accounting for 26 episodes (30.6%). Other notable pathogens included Corynebacterium diphtheriae (10 cases, 11.8%) and Streptococcus pyogenes (7 cases, 8.2%). In 6 episodes, the microbiologic diagnosis was made by 16S ribosomal RNA testing of excised cardiac tissue.

CONCLUSIONS

Congenital heart disease was the major risk factor for IE; however, rheumatic heart disease is also an important risk factor in New Zealand, with implications for local endocarditis prophylaxis recommendations. In addition to a high burden of healthcare-associated and staphylococcal IE, pathogens such as C. diphtheriae and S. pyogenes occurred. 16S ribosomal RNA testing is a useful tool to determine the etiologic agent in culture-negative IE.

Superior mesenteric artery aneurysm in a patient with infective endocarditis

Infective endocarditis (IE) is a rare but serious condition. We present a case of endocarditis in a healthy 40-year-old male with no predisposing conditions. His physical examination was suggestive of peripheral microembolization and prompted us to consider the diagnosis of IE and order the appropriate investigations. After treatment, he later presented to the emergency department with abdominal pain, and a superior mesenteric artery aneurysm was discovered. We discuss recent advances in the changing epidemiology and microbiology of IE, review the presentation and diagnosis of IE, and highlight the potential complications of this disease.

Profile of infective endocarditis observed from 2003 - 2010 in a single center in Italy

Background

This study aimed to provide a contemporary picture of the epidemiologic, clinical, microbiologic characteristics and in-hospital outcome of infective endocarditis (IE) observed in a single center in Italy.

Methods

We performed a retrospective study of patients with definite or probable IE observed at the “L. Sacco” Hospital in Milan, Italy, from January 1, 2003 through December 31, 2010.

Results

189 episodes of IE in 166 patients were included. The mean number of incident IE in the study period was of 1.27 (range 0.59-1.76) cases per 1000 patients admitted. The median age of the cohort was 57 (interquartile range, 43-72) years, 63% were male and 62.5% had native valve IE. Twenty-six percent were active intravenous drug users (IVDU), 29% had a health care-associated IE and 5% chronic rheumatic disease. Twenty-nine percent of the cases occurred in patients affected by chronic liver disease and 19% in HIV positive subjects. Staphylococcus aureus was the most common pathogen (30%), followed by streptococci. The mitral (34%) and aortic (31%) valves were involved most frequently. The following complications were common: stroke (19%), non-stroke embolizations (25%), heart failure (26%) and intracardiac abscess (9%). Surgical treatment was frequently employed (52%) but in hospital mortality remained high (17%). Health care-associated IE and complications were independently associated with an increased risk of in-hospital death, while surgery was associated with decreased mortality.

Conclusion

S. aureus emerged as the leading causative organism of IE in a University hospital in northern Italy. Our study confirmed the high in-hospital mortality of IE, particularly if health care associated, and the protective role of surgery.

Epidemiology of infective endocarditis in Spain in the last 20 years

Infective endocarditis is an uncommon disease, with an estimated incidence of 3.1 to 3.7 episodes per 100 000 inhabitants/year. The incidence is highest in elderly people. The microorganisms most frequently isolated in infective endocarditis are staphylococci and streptococci. In the last few decades, the spectrum of heart diseases predisposing to infective endocarditis has changed, since degenerative heart disease is the most common valve disease, and there are an increasing number of infective endocarditis patients without previously known valve disease. In addition, up to one-third of infective endocarditis patients become infected through contact with the health system. These patients are more frail, which leads to higher in-hospital mortality. As a result of substantial epidemiological changes, few cases of infective endocarditis can be prevented by antibiotic prophylaxis. Despite advances in medical and surgical treatment, in-hospital mortality among infective endocarditis patients is high. Nevertheless, there is room for improvement in reducing the rate of nosocomial bacteremia, the prompt diagnosis of infective endocarditis in at-risk patients, and the early identification of patients with a highest risk of complications, as well as in the creation of multidisciplinary teams for the management of this disease.

Neurological Complications of Infective Endocarditis

Background—

The purpose of this study was to assess the incidence of neurological complications in patients with infective endocarditis, the risk factors for their development, their influence on the clinical outcome, and the impact of cardiac surgery.

Methods and Results—

This was a retrospective analysis of prospectively collected data on a multicenter cohort of 1345 consecutive episodes of left-sided infective endocarditis from 8 centers in Spain. Cox regression models were developed to analyze variables predictive of neurological complications and associated mortality. Three hundred forty patients (25%) experienced such complications: 192 patients (14%) had ischemic events, 86 (6%) had encephalopathy/meningitis, 60 (4%) had hemorrhages, and 2 (1%) had brain abscesses. Independent risk factors associated with all neurological complications were vegetation size ≥3 cm (hazard ratio [HR] 1.91), Staphylococcus aureus as a cause (HR 2.47), mitral valve involvement (HR 1.29), and anticoagulant therapy (HR 1.31). This last variable was particularly related to a greater incidence of hemorrhagic events (HR 2.71). Overall mortality was 30%, and neurological complications had a negative impact on outcome (45% of deaths versus 24% in patients without these complications; P <0.01), although only moderate to severe ischemic stroke (HR 1.63) and brain hemorrhage (HR 1.73) were significantly associated with a poorer prognosis. Antimicrobial treatment reduced (by 33% to 75%) the risk of neurological complications. In patients with hemorrhage, mortality was higher when surgery was performed within 4 weeks of the hemorrhagic event (75% versus 40% in later surgery).

Conclusions—

Moderate to severe ischemic stroke and brain hemorrhage were found to have a significant negative impact on the outcome of infective endocarditis. Early appropriate antimicrobial treatment is critical, and transitory discontinuation of anticoagulant therapy should be considered.

Perforation of mitral-aortic intervalvular fibrosa secondary to bicuspid aortic valve endocarditis: Possible relation with diagnostic coronary angiography

Infective endocarditis (IE) remains a serious and deadly disease despite recent advances in diagnosis and treatment. In all IE cases, the rate of healthcare-associated IE has been reported as 23%. Aortic valve endocarditis may extend to mitral-aortic intervalvular fibrosa (MAIVF), which may cause pseudoaneurysm formation and subsequent perforation. Direct perforation of the MAIVF is a rare clinical finding. In this report, we present a case of bicuspid aortic valve endocarditis which manifested as acute heart failure secondary to perforation of MAIVF and developed after diagnostic coronary angiography. <Learning objective: Direct perforation of MAIVF without abscess or aneurysm formation is a rare complication of IE. Health-care associated IE (HAIE) occurs mostly secondary to vascular manipulations and coronary angiography (CAG) is a rare cause of HAIE. Here, we report a case of aortic valve IE which developed two weeks after CAG and was complicated with perforation of MAIVF. Staphylococcus epidermidis was the causative microorganism. Urgent surgical treatment resulted in complete recovery of the patient.>.

Device-related infective endocarditis, with special consideration of implanted intravascular and cardiac devices in a predominantly male population

BACKGROUND

The relationship between invasive medical devices and infective endocarditis (IE) has not been comprehensively assessed. We describe our experience of patients with IE, with particular attention to the role of pre-existing intravascular catheters and implanted cardiac devices in the pathogenesis.

METHODS

We performed a retrospective review of hospital records over a 10-y period (1997-2007), and included patients with 'definite' or 'possible' IE as per the modified Duke criteria. The complete electronic medical record was reviewed for the presence of intravascular devices prior to the onset of IE, including intravascular catheters and implanted cardiac devices (defibrillators and pacemakers).

RESULTS

We identified 155 patients with IE. Infection involved a native valve in 124 (80%) patients and a prosthetic valve in 15 (9.7%). In the remaining 16 (10.3%) patients, infection was attributed to an implanted cardiac device. The most commonly identified source of infection was a central venous catheter, accounting for 17.4% of patients, followed by an implanted cardiac device in 10.3% of patients. Staphylococcus aureus was the most commonly isolated organism in catheter-associated IE and cardiac device-associated IE (31.9% and 62.5%, respectively). Thirty-five (22.5%) patients died within 90 days. Mortality was 31.9% in patients with IE caused by methicillin-resistant S. aureus (MRSA).

CONCLUSIONS

Intravascular catheters and cardiac implantable devices are common sources of infection leading to IE, and the intracardiac devices themselves often become infected, with MRSA as the predominant pathogen.