Contemporary management of endocarditis

More than a century ago, Osler took numerous syndrome descriptions of cardiac valvular infection that were incomplete and confusing and categorized them into the cardiovascular infections known as infective endocarditis. Because he was both a clinician and a pathologist, he was able to provide a meaningful outline of this complex disease. Technical advances have allowed us to better subcategorize infective endocarditis on the basis of microbiological etiology. More recently, the syndromes of infective endocarditis and endarteritis have been expanded to include infections involving a variety of cardiovascular prostheses and devices that are used to replace or assist damaged or dysfunctional tissues (Table 1). Taken together, infections of these novel intracardiac, arterial, and venous devices are frequently seen in medical centers throughout the developed world. In response, the American Heart Association’s Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease wrote this review to assist and educate clinicians who care for an increasing number of patients with nonvalvular cardiovascular device–related infections. Because timely guidelines1,2 exist that address the prevention and management of intravascular catheter–related infections, these device-related infections are not discussed in the present Statement. View this table: TABLE 1. Nonvalvular Cardiovascular Device–Related Infections This review is divided into two broad sections. The first section examines general principles for the evaluation and management of infection that apply to all nonvalvular cardiovascular devices. Despite the marked variability in composition, structure, function, and frequency of infection among the various types of nonvalvular cardiovascular devices reviewed in this article, there are several areas of commonality for infection of these devices. These include clinical manifestations, microbiology, pathogenesis, diagnosis, treatment, and prevention. The second section addresses each device and describes unique clinical features of infection. Each device is placed into one of 3 categories—intracardiac, arterial, or venous—for discussion. ### Clinical Manifestations The specific signs and symptoms associated with an infection of a …

Diagnosing Endocarditis: Get the Picture?!

Enterococcal cardiovascular implantable electronic device (CIED) infections are not well characterized. Data from the Multicenter Electrophysiologic Device Infection Cohort, a prospective study of CIED infections, were used for descriptive analysis of adults with enterococcal CIED infections. Of 433 patients, 21 (4.8%) had enterococcal CIED infection. Median age was 71 years. Twelve patients (57%) had permanent pacemakers, five (24%) implantable cardioverter defibrillators, and four (19%) biventricular devices. Median time from last procedure to infection was 570 days. CIED-related bloodstream infections occurred in three patients (14%) and 18 (86%) had infective endocarditis (IE), 14 (78%) of which were definite by the modified Duke criteria. IE cases were classified as follows: valvular IE, four; lead IE, eight; both valve and lead IE, six. Vegetations were demonstrated by transesophageal echocardiography in 17 patients (81%). Blood cultures were positive in 19/19 patients with confirmed results. The most common antimicrobial regimen was penicillin plus an aminoglycoside (33%). Antibiotics were given for a median of 43 days. Only 14 patients (67%) underwent device removal. There was one death during the index hospitalization with four additional deaths within 6 months (overall mortality 24%). There were no relapses. Enterococci caused 4.8% of CIED infections in our cohort. Based on the late onset after device placement or manipulation, most infections were likely hematogenous in origin. IE was the most common infection syndrome. Only 67% of patients underwent device removal. At 6 months follow-up, no CIED infection relapses had occurred, but overall mortality was 24%.

Infectious endocarditis (IE) is an infection of the heart’s innermost layer, the endothelium. Most cases require a predisposing injury to the endocardium to serve as a nidus for thrombus development, which in turn acts as nidus for bloodstream microorganisms. These intravascular microorganisms can result from dental and other invasive procedures, infected vascular catheters, and skin lesions. However, most episodes of IE result from transient bacteremia during menial tasks, such as chewing and brushing one’s teeth. Blood cultures and echocardiograms are critical for IE diagnosis. Transesophageal echocardiogram (TEE) is the preferred diagnostic tool for prosthetic valve endocarditis and cardiovascular implantable electronic device (CIED) infections. IE complicated by heart failure and cerebral emboli has high rates of morbidity and mortality. Large vegetation, mobile lesions, mitral valve vegetation, and infection by S. aureus and fungi are more likely to result in embolic phenomena. Indications for surgery include severe heart failure, persistent infection, fungal infection, heart block, and abscess formation.

Context: Infective endocarditis (IE) is associated with high morbidity and mortality despite advances in diagnosis and treatment. A recent knowledge of the epidemiology and clinical spectrum of IE is essential for prompt recognition and effective therapy. Aims: This study aims to determine the clinical profile, and outcome of patients with IE and to identify the clinical and laboratory predictors of poor prognosis in patients with IE. Settings and Design: This is a prospective observational study among patients diagnosed with IE in a tertiary care center over a period of 12 months. Subjects and Methods: We collected the demographic, clinical, and laboratory evaluation details of consecutive patients admitted with IE. All the patients were followed during hospitalization for mortality, complications, and need for surgery. Statistical Analysis Used: The comparison of mean values across the different outcome groups was done using one-way analysis of variance test. The association between the categorical independent variables with the outcome was evaluated using the Pearson Chi-square test. Results: Among 75 patients admitted with IE rheumatic heart disease was the most common predisposing condition. Blood culture was positive in 80%. Staphylococcus aureus was the most common organism. Total in-hospital mortality was 32%. Staphylococcal IE had 43% mortality and fungal IE had 57% mortality. Prosthetic valve endocarditis also had 57% mortality. Surgery was undertaken in 28% of patients and surgical mortality was 19%. Presence of heart failure, thrombocytopenia, leukocytosis, elevated neutrophil-to-lymphocyte ratio, elevated platelet-to-lymphocyte ratio, high serum creatinine, and C-reactive protein were associated with high mortality. Conclusions: The mortality associated with IE remains high. Clinical and laboratory parameters can reliably predict poor prognosis in IE.

The diagnosis of infective endocarditis (IE) is often challenging and based on careful integration of clinical, microbiological, and imaging findings. The classical diagnostic scores (e.g. Duke criteria) have drawbacks as they leave clinicians with a considerable number of uncertain cases, in which further management is unclear and important therapeutic actions possibly delayed. Transoesophageal echocardiography is the preferred imaging technique for the diagnosis of IE as it can visualize valvular vegetations and paravalvular complications with high accuracy. However, transoesophageal echocardiography has limitations in the case of device-associated endocarditis (i.e. prosthetic valve (PVE) or cardiovascular implantable electronic device (CIED) infection). Radionuclide imaging techniques using 18F-fluorodeoxyglucose positron emission tomography (FDG PET) or white blood cell single-photon emission computed tomography (WBC SPECT) are accurate techniques to pick-up inflammatory cells. They have shown incremental diagnostic value for detecting PVE and CIED infection. Adding computed tomography angiography allows accurate co-registration of inflammatory signal and anatomical structure, and improves the detection of paravalvular complications such as abscesses or pseudoaneurysms. Current European Society of Cardiology guidelines have recently adopted the use of FDG PET/CT or WBC SPECT/CT in their recommendations for the work-up of suspected or uncertain PVE.

The diagnosis of infective endocarditis (IE) is often challenging and based on careful integration of clinical, microbiological, and imaging findings. The classical diagnostic scores (e.g. Duke criteria) have drawbacks as they leave clinicians with a considerable number of uncertain cases, in which further management is unclear and important therapeutic actions possibly delayed. Transoesophageal echocardiography is the preferred imaging technique for the diagnosis of IE as it can visualize valvular vegetations and paravalvular complications with high accuracy. However, transoesophageal echocardiography has limitations in the case of device-associated endocarditis (i.e. prosthetic valve (PVE) or cardiovascular implantable electronic device (CIED) infection). Radionuclide imaging techniques using 18F-fluorodeoxyglucose positron emission tomography (FDG PET) or white blood cell single-photon emission computed tomography (WBC SPECT) are accurate techniques to pick-up inflammatory cells. They have shown incremental diagnostic value for detecting PVE and CIED infection. Adding computed tomography angiography allows accurate co-registration of inflammatory signal and anatomical structure, and improves the detection of paravalvular complications such as abscesses or pseudoaneurysms. Current European Society of Cardiology guidelines have recently adopted the use of FDG PET/CT or WBC SPECT/CT in their recommendations for the work-up of suspected or uncertain PVE.

Update on the epidemiology, diagnosis, and management of infective endocarditis: A review

Multimodality imaging plays a pivotal role in the evaluation and management of infective endocarditis (IE)-a condition with high morbidity and mortality. The diagnosis of IE is primarily based on the modified Duke criteria with echocardiography as the first-line imaging modality. Both transthoracic and transesophageal echocardiography delineate vegetation location and size, assess for paravalvular extension of infection, and have the added advantage of defining the hemodynamic effects of valvular or device infection. Native and prosthetic valve IE, infections relating to cardiac implantable electronic devices, and indwelling catheters are effectively evaluated with echocardiography. However, complementary imaging is occasionally required when there remains diagnostic uncertainty following transesophageal echocardiography. Multidetector computed tomography and nuclear imaging techniques such as positron emission tomography and white blood cell scintigraphy have been shown to reduce the rate of misdiagnosed IE particularly in the setting of prosthetic valve endocarditis, paravalvular extension of infection, and cardiac implantable electronic devices. In this review, we describe a modern approach to cardiac imaging in native and prosthetic valve endocarditis, as well as cardiac implantable electronic devices including pacing devices and left ventricular assist devices. Current guidelines addressing the role of multimodality imaging in IE are discussed. The utility of imaging in the assessment of local and distant endocarditis complications such as pericardial sequelae, myocarditis, and embolic events is also addressed.

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.

Background Improving early screening for Infective Endocarditis (IE) in bloodstream infections (BSIs) is crucial due to the high morbidity and mortality rates. Additionally, it is imperative to ensure the cost-effectiveness of imaging tests. Despite the potential of epidemiology to identify high-risk IE patients, there remains a significant lack of data on the prevalence of IE according to microbiological etiology in BSIs. Purpose To investigate the risk according to microbiological etiology and echocardiographic screening of IE cases among BSIs. Methods A single-center observational registry between January 2015 and December 2021. All consecutive hospitalized adults with BSIs were included. The echocardiographic screening for IE and the prevalence of definitive IE diagnosis was assessed. All clinically significant hemoculture with the same microorganism during the same hospitalization was considered as one BSI. Results Among 4939 BSIs related to 4242 admissions in 3708 patients analyzed [74 (64-83) years; 2882 (58.7%) male],133 (2.7%) BSIs were identified as definite IE. The most prevalent pathogens in BSIs (Figure 1) were Enterobacterales (48.3%), Staphylococcus aureus (11.5%), and Anaerobic species (7.6%). Patients with Streptococcus bovis complex BSI had the highest risk of IE (19.2%), followed by Listeria monocytogenes BSI (16.7%) and Enterococcus faecalis BSI (15.5%). Following the selection of only IE typical species according to the main IE diagnostics criteria (Figure 1), the high IE risks are underestimated in some aggregation groups (Streptococci) or no considering some as non-typical (Listeria monocytogenes), or more clear risks in more detailed microorganisms (Streptococcus gallolyticus) or in specific species in the presence of intracardiac material. The highest rate of echocardiography screening for IE (Figure 2) occurred in the BSIs caused by Staphylococcus aureus with 75%, followed by Other Streptococci (72.7%), Staphylococcus lugdunensis (72.2%), and Streptococcus bovis complex (66.9%). Although the IE prevalence was high in the Listeria monocytogenes, Enterococcus faecalis, and HACEK BSIs, echocardiographic screening was performed from 41.7% to 66.3%. The echocardiography screening was higher in the presence of intracardiac prosthesis material, ranging from 40 to 100% of BSI with this condition. Among BSIs groups without IE cases, echocardiography screening was performed in 27.3% to 59.4%. Conclusions Our data illustrates a discrepancy between the prevalence of BSI species and their risk of IE. We also demonstrated how a narrow focus on typical species in the main IE diagnostic criteria can lead to a misleading risk analysis. Our analysis of echocardiographic screening in patients with BSIs for detecting IE demonstrated that it could be optimized considering these disparities.

Infective endocarditis: Perioperative management and surgical principles

79-Year-Old Man With Shortness of Breath and Fevers

BACKGROUND AND OBJECTIVE:Data on infective endocarditis prevalence, epidemiology and etiology from Saudi Arabia and the Gulf region are sparse. We undertook this study to describe the pattern and the causative agents of endocarditis at a hospital in Saudi Arabia.METHODS:We conducted a retrospective analysis of all reported endocarditis cases at the Dhahran Health Center from January 1995 to December 2008.RESULTS:Of the 83 cases of endocarditis, 54 (65%) were definite endocarditis and the remaining 29 (35%) were possible endocarditis based on the Duke criteria. Patients with definite endocarditis included 39 males and 15 females (ratio of 2.6:1) with a mean age (SD) of 59.7 (18.2) years. Of the definite endocarditis cases, native valve endocarditis occurred in 44 (81.5%) cases of and prosthetic valve endocarditis was observed in 10 (18.5%). The most commonly involved valves were mitral (n=24; 44.4%) and aortic (n=20; 39.2%). The most common organisms were S aureus (n=23; 42.6%), Enterococcus faecalis (n=12; 22.2%) and viridans streptococci (n=9; 16.7%). Surgical intervention was required in 17 (31.4%) cases and the in-hospital mortality rate was 29.4% (n=15). Of all the patients, 3 (5.5%) had embolic stroke as a complication.CONCLUSION:Native valve endocarditis is the predominant type of endocarditis. The patients were older adults and the most common organisms were S aureus, E faecalis and viridans streptococci.

BackgroundInfection remains a major complication of cardiac implantable electronic devices and can lead to significant morbidity and mortality. Implantable devices that avoid transvenous leads, such as the subcutaneous implantable cardioverter‐defibrillator (S‐ICD), can reduce the risk of serious infection‐related complications, such as bloodstream infection and infective endocarditis. While the 2017 AHA/ACC/HRS guidelines include recommendations for S‐ICD use for patients at high risk of infection, currently, there are no clinical trial data that address best practices for the prevention of S‐ICD infections. Therefore, an expert panel was convened to develop a consensus on these topics.MethodsAn expert process mapping methodology was used to achieve consensus on the appropriate steps to minimize or prevent S‐ICD infections. Two face‐to‐face meetings of high‐volume S‐ICD implanters and an infectious diseases specialist, with expertise in cardiovascular implantable electronic device infections, were conducted to develop consensus on useful strategies pre‐, peri‐, and postimplant to reduce S‐ICD infection risk.ResultsExpert panel consensus on recommended steps for patient preparation, S‐ICD implantation, and postoperative management was developed to provide guidance in individual patient management.ConclusionAchieving expert panel consensus by process mapping methodology for S‐ICD infection prevention was attainable, and the results should be helpful to clinicians in adopting interventions to minimize risks of S‐ICD infection.