Infective endocarditis at a tertiary care hospital in South Korea

Infective Endocarditis-Characteristics and Prognosis According to the Affected Valves

BACKGROUND

Infective endocarditis (IE) continues to be a disease with high mortality despite medical advances.

OBJECTIVE

The objective of this study was to investigate the characteristics and prognosis of IE according to the affected valves.

MATERIALS AND METHODS

This study was retrospective and single-centered, and it included 270 patients with a diagnosis of IE, for the period 2005-2021, who received treatment at the University Hospital "St. Georgi" in Plovdiv, Bulgaria.

RESULTS

Single-valve IE (SIE) was found in 82.6% (n-223), multivalvular IE (MIE) in 16.66% (n = 45) and device IE (CDRIE) in 0.74% (n = 2) of patients. The most commonly affected valve was the aortic valve, in 44.8% (n = 121). The predominant multivalvular involvement was aortic-mitral valves (AV-MV) (13.7%, n = 37). The patients with tricuspid valve (TV) IE were significantly younger, at 39 (30) years, and were more frequently male (80.8%). Mortality was higher in MIE than in SIE (31.1% vs. 23.8%) and was the highest in multivalve aortic-tricuspid (AV-TV) IE (75%). Early surgery was performed most in AV-MV IE, in 29.7% (n = 11). The Charlson comorbidity index (CCI) was significantly higher in MV 4 (4) and AV 3 (3) vs. TV IE 1 (5) (p = 0.048 and p = 0.011, respectively). Septic shock occurred most frequently in AV-TV involvement (75%; p = 0.0001). The most common causative agents were of the Staphylococcus group. Staphylococcus aureus more often affected TV alone (46.2%, n = 124) vs. AV (9.9%, n = 14; p = 0.0001) and vs. MV (22.6%, n = 17; p = 0.022); Staphylococcus coagulase-negative (CNG) was the prevalent cause of MV IE (22.7%, n = 17) vs. AV-MV (2.7%, n = 1; p = 0.007). Streptococci were represented in a low percentage and only in left-sided IE, more frequently in AV-MV (18.9%, n = 7) vs. AV (6.6%, n = 8; p = 0.025).

CONCLUSIONS

The aortic valve is the most frequently affected valve, as single-valve IE or as multivalve AV-MV, with the predominant causative agents being of the Staphylococcus group. AV-TV IE has the worst prognosis, with the most common complication of septic shock and the highest in-hospital mortality.

Effects of dexmedetomidine on renal function after cardiac surgery for infective endocarditis: An interim analysis of a randomized controlled trial

BACKGROUND

Patients undergoing cardiac surgery for infective endocarditis (IE) are at a high risk of postoperative acute kidney injury (AKI) owing to heightened systemic inflammation. Therefore, we aimed to investigate the effect of dexmedetomidine on postoperative AKI in patients who underwent cardiac surgery for IE.

METHODS

A total of 63 patients who underwent cardiac surgery for IE were randomly assigned to receive either intravenous dexmedetomidine infusion of 0.4 μg kg-1 h-1 (DEX group) or normal saline infusion (control group) for 24 h after induction of anesthesia. The occurrence of AKI within seven days postoperation, epinephrine, norepinephrine, and interleukin-6 levels, as well as postoperative morbidities, were assessed. An intertrim analysis was conducted using Pocock's alpha spending function at α = 0.05 and β = 0.2.

RESULTS

This trial was early terminated according to the results of interim analysis performed when 60 % of the pre-set number of patients have been collected. The incidence of AKI was significantly lower in the DEX group than in the control group (32.3 % vs. 9.4 %, p = 0.025). Patients in the DEX group had significantly lower epinephrine levels than those in the control group, whereas norepinephrine and interleukin-6 levels were similar. Perioperative mean arterial pressure or heart rate did not differ between the groups.

CONCLUSIONS

Dexmedetomidine administration for 24 h starting from induction of anesthesia significantly reduced the incidence of postoperative AKI after cardiac surgery for IE (by 29 % vs. control) without hemodynamic side effects. This was accompanied by a significant attenuation of postoperative increase in serum epinephrine levels.

Risk and Outcome of Infective Endocarditis in Streptococcal Bloodstream Infections according to Streptococcal Species

This study aimed to identify which streptococcal species are closely associated with infective endocarditis (IE) and to evaluate risk factors for mortality in patients with streptococcal IE. We performed a retrospective cohort study of all patients with streptococcal bloodstream infection (BSI) from January 2010 to June 2020 in a tertiary hospital in South Korea. We compared clinical and microbiological characteristics of streptococcal BSIs according to the diagnosis of IE. We performed multivariate analysis to evaluate the risk of IE according to streptococcal species and risk factors for mortality in streptococcal IE. A total of 2,737 patients were identified during the study period, and 174 (6.4%) were diagnosed with IE. The highest IE prevalence was in patients with Streptococcus mutans BSI (33% [9/27]) followed by S. sanguinis (31% [20/64]), S. gordonii (23% [5/22]), S. gallolyticus (16% [12/77]), and S. oralis (12% [14/115]). In multivariate analysis, previous IE, high-grade BSI, native valve disease, prosthetic valve, congenital heart disease, and community-onset BSI were independent risk factors for IE. After adjusting for these factors, S. sanguinis (adjusted OR [aOR], 7.75), S. mutans (aOR, 5.50), and S. gallolyticus (aOR, 2.57) were significantly associated with higher risk of IE, whereas S. pneumoniae (aOR, 0.23) and S. constellatus (aOR, 0.37) were associated with lower risk of IE. Age, hospital-acquired BSI, ischemic heart disease, and chronic kidney disease were independent risk factors for mortality in streptococcal IE. Our study points to significant differences in the prevalence of IE in streptococcal BSI according to species. IMPORTANCE Our study of risk of infective endocarditis in patients with streptococcal bloodstream infection demonstrated that Streptococcus sanguinis, S. mutans, and S. gallolyticus were significantly associated with higher risk of infective endocarditis. However, when we evaluated the performance of echocardiography in patients with streptococcal bloodstream infection, patients with S. mutans and S. gordonii bloodstream infection had a tendency of low performance in echocardiography. There are significant differences in the prevalence of infective endocarditis in streptococcal bloodstream infection according to species. Therefore, performing echocardiography in streptococcal bloodstream infection with a high prevalence of, and significant association with, infective endocarditis is desirable.

Temporal trends and patterns of infective endocarditis in a Chinese population: A territory-wide study in Hong Kong (2002–2019)

Background

The characteristics of infective endocarditis (IE) in Asians are poorly understood. Therefore, we aim to describe the epidemiological trends and clinical features of IE in Hong Kong.

Methods

All patients with incident IE from 2002–2019 in a territory-wide clinical database in Hong Kong were identified. We studied the age- and sex-adjusted and one-year mortality of IE between 2002 and 2019 and identified significant contributors to 1-year all-cause death using the attributable fraction. We used propensity score and inverse propensity of treatment weighting to study the association of surgery with mortality.

Findings

A total of 5139 patients (60.4 ± 18.2years, 37% women) were included. The overall incidence of IE was 4.9 per 100,000 person-year, which did not change over time (P = 0.17). Patients in 2019 were older and more comorbid than those in 2002. The one-year crude mortality rate was 30% in 2002, which did not change significantly over time (P = 0.10). Between 2002 and 2019, the rate of surgery increased and was associated with a 51% risk reduction in 1-year all-cause mortality (Hazard Ratio 0.49 [0.28–0.87], P = 0.015). Advanced age (attributable fraction 19%) and comorbidities (attributable fraction 15%) were significant contributors to death.

Interpretation

The incidence of IE in Hong Kong did not change between 2002 and 2019. Patients with IE in 2019 were older and had more comorbidities than those in 2002. Mortality of IE remains persistently high in Hong Kong. Together, these data can guide public health strategies to improve the outcomes of patients with IE.

Funding

This work was supported by Sanming Project of Medicine in Shenzhen, China [No. SZSM201911020] and HKU-SZH Fund for Shenzhen Key Medical Discipline [No. SZXK2020081].

Comparing Treatment Outcomes of Ampicillin-Sulbactam, Other β-Lactams, and Vancomycin in Blood Culture-Negative Infective Endocarditis

Selection of proper antibiotics for blood culture-negative infective endocarditis (BCNIE) is difficult due to limited data on antibiotic regimens for BCNIE in existing literature. The aim of this study was to compare ampicillin-sulbactam, other β-lactams antibiotics, and vancomycin among patients with BCNIE to determine the proper antibiotic regimens. This retrospective study included adult patients with BCNIE admitted to Severance Hospital from November 2005 to August 2017. Patients were classified into three groups as, treated with ampicillin-sulbactam, other β-lactams, and vancomycin. The primary outcome was 1-year all-cause mortality. A total of 74 cases with BCNIE were enrolled in this study. There were no statistically significant differences in clinical characteristics between the three groups. One-year mortality did not significantly differ between the study groups either. Further, in-hospital mortality, 28-day mortality and overall mortality showed no difference. However, Cox-regression analysis showed nosocomial infective endocarditis as an independent risk factor and a protective effect of surgery on 1-year mortality. This study showed no clear difference in the outcomes of BCNIE as per the antibiotic therapy but suggested the beneficial effect of surgical treatment. With increasing global concern of antimicrobial resistance, it might be reasonable to select ampicillin-sulbactam-based antibiotic therapy while actively considering surgical treatment in BCNIE.

Epidemiological investigation and physician awareness regarding the diagnosis and management of Q fever in South Korea, 2011 to 2017

BACKGROUND

In South Korea, the number of Q fever cases has rapidly increased since 2015. Therefore, this study aimed to characterize the epidemiological and clinical features of Q fever in South Korea between 2011 and 2017.

METHODS/PRINCIPAL FINDINGS

We analyzed the epidemiological investigations and reviewed the medical records from all hospitals that had reported at least one case of Q fever from 2011 to 2017. We also conducted an online survey to investigate physicians' awareness regarding how to appropriately diagnose and manage Q fever. The nationwide incidence rate of Q fever was annually 0.07 cases per 100,000 persons. However, there has been a sharp increase in its incidence, reaching up to 0.19 cases per 100,000 persons in 2017. Q fever sporadically occurred across the country, with the highest incidences in Chungbuk (0.53 cases per 100,000 persons per year) and Chungnam (0.27 cases per 100,000 persons per year) areas. Patients with acute Q fever primarily presented with mild illnesses such as hepatitis (64.5%) and isolated febrile illness (24.0%), whereas those with chronic Q fever were likely to undergo surgery (41.2%) and had a high mortality rate (23.5%). Follow-up for 6 months after acute Q fever was performed by 24.0% of the physician respondents, and only 22.3% of them reported that clinical and serological evaluations were required after acute Q fever diagnosis.

CONCLUSIONS

Q fever is becoming an endemic disease in the midwestern area of South Korea. Given the clinical severity and mortality of chronic Q fever, physicians should be made aware of appropriate diagnosis and management strategies for Q fever.

Surgical treatment for infective endocarditis in the ageing society: a nationwide retrospective study in Japan

Objective

The current status of surgical treatment for infective endocarditis (IE) among very elderly people is unclear.

Methods

We extracted data on patients in Japan with community-acquired IE who were admitted and discharged between April 2010 and February 2018 using a nationwide inpatient, the Diagnosis Procedure Combination database. We divided patients into three groups: non-elderly (<65 years), elderly (65–79 years) and very elderly (≥80 years). A 1:1 propensity score matching was performed to compare proportions of surgical treatment and in-hospital mortality among the groups.

Results

We identified 20 667 eligible patients (median age 70 years, 61.0% men). The proportion of very elderly patients significantly increased (19.1% in 2010 to 29.7% in 2018). The proportion of surgical treatment was significantly lower, and in-hospital mortality was significantly higher in very elderly patients. This tendency was more pronounced among patients with in-hospital complications such as heart failure, stroke or embolism. Surgical treatment was significantly associated with lower in-hospital mortality even in very elderly patients, both in an unmatched (OR 0.61; 95% CI 0.47 to 0.78) and a propensity score matched cohort (OR 0.61; 95% CI 0.43 to 0.85).

Conclusions

The proportion of very elderly patients with IE was increasing, and very elderly patients had higher in-hospital mortality. The proportion of surgical treatment for IE among very elderly patients was low, but it was associated with lower in-hospital mortality. Further studies are needed to establish the optimal strategy for IE among very elderly patients.