Course Of Infective Endocarditis Research Articles

Neurological complications of infective endocarditis - a review

Introduction and purpose Infective endocarditis (IE) is a disease resulting from infection of the endocardium. In addition to cardiac symptoms, frequent complications of IE include various damage to the nervous system. The aim of this study is to describe the current state of knowledge about the neurological complications of infective endocarditis. Methods Medical publications were reviewed using the "PubMed" and "Google Scholar" databases. The obtained results were verified in terms of the following criteria: publication in 2016, retrospective analysis, obtaining 44 papaers covering a total of 8067 patients. The information was supplemented with case reports and meta-analyses. Description of the state of knowledge Neurologic complications occur in 20 to 60% of patients with IE. The most common is ischemic stroke, the symptoms of which may precede the diagnosis of IE. Less common complications that often remain asymptomatic include mycotic aneurysms and intracranial hemorrhages. Infectious material entering the brain may also cause meningitis and brain abscess. However, these complications do not occur often. Magnetic resonance imaging of the head is an effective test for detecting neurological damage in the course of IE. The recommendation for routine use of this test is debatable. In addition to antibiotic therapy, cardiac surgery is used to treat IE to remove bacterial vegetation. Research indicates the high effectiveness of this type of surgery in the prevention and treatment of neurological complications of infective endocarditis.

Impact of Neurological Complications on Long-Term Outcomes in Patients with Infective Endocarditis.

Neurological complications are frequent during the active course of infective endocarditis (IE), and they are associated with high in-hospital mortality rates. However, limited data exist on the prognostic value of these complications for late outcomes. This study aimed to assess the long-term impact of neurological complications in patients surviving an IE episode. A total of 263 consecutive IE patients admitted to a tertiary care center between 2007 and 2022 were prospectively included. Neurological complications at admission included transient ischemic attack (TIA), ischemic stroke, hemorrhagic stroke, intracerebral abscess, and meningitis. The primary outcome was a composite of overall mortality or heart valve surgery. Of the patients, 34.2% died in the hospital, leaving 173 survivors for long-term follow-up. Over a median of 3.5 years, 29 patients died, and 13 (9%) underwent cardiac surgery, resulting in an overall adverse event rate of 30%. Neurological complications independently predicted long-term adverse outcomes (hazard ratio (HR) 2.237; 95% CI 1.006-4.976), after adjusting for age, chronic kidney disease (CKD), and heart failure (HF) development. In an IE patient cohort, neurological complications at admission, which is a complication directly related to the IE process, were independent predictors of long-term outcomes.

Proinflammatory cytokines IL-6, IL-1β, TNF-α in infective endocarditis

Aim. To study the features of macrophages in the tissues of resected valves in operated patients with infective endocarditis (IE), their significance and interaction with inflammatory markers to improve the effectiveness of IE diagnosis. Materials and methods. Prospectively the research included 25 adult patients with active IE (Duke criteria 2015) and 24 patients with heart defects without IE, hospitalized in a cardiosurgical hospital in Moscow (2021–2022). A standard laboratory and instrumental examination was carried out for the diagnosis of IE, including etiological diagnosis with microbiological and molecular biological methods, and echocardiographic examination of heart. Additionally, the neutrophil-to-lymphocyte ratio (NLR) was calculated. The study of macrophages was carried out in the tissues of resected valves with the determination of the expression of pro- and anti-inflammatory cytokine genes, macrophage markers (CD 68+) using real-time PCR. Results. Increased expression of proinflammatory cytokines IL-1β, TNF-α and IL-6 was revealed in the group of operated patients with IE with significant differences in IL-1β (CI [IQR] 0.00367 [0.00047–0.01553] vs 0.00018 [0.00012–0.00262]; p0.05) and IL-6 (CI [IQR] 0.00367 [0.00047–0.01553] vs 0.00018 [0.00012–0.00262]; p0.05) and IL-6 (CI [IQR] 0.00338 [0.00066–0.01674] vs 0.00054 [0.00044–0.00378]; p0.05). The expression of anti-inflammatory cytokines in valve tissues prevailed in the control group without significant differences from patients with IE. The macrophage marker CD 68+ was revealed in all examined patients with a significant quantitative predominance in the group of patients with IE. There were no differences in the expression of pro- and anti-inflammatory cytokines depending on the presence of embolic events, intracardiac complications, etiological affiliation to S. aureus, as well as hospital mortality and combined endpoint (death from all causes or recurrence of IE 6 months after surgery) in patients with IE with or without events. Cytokines IL-1β and IL-6 positively correlated with each other, with leukocytes and NLR. ROC analysis determined that IL-1β and NLR had the most favorable features for the diagnosis of IE [IL-1β AUC 0.816 (p=0.02), NLR AUC 0.807 (p=0.03)]. IL-6 did not show a diagnostic value in IE. The threshold value for IL-1β was 0.00029 (sensitivity 86.4%, specificity 60.0%, prognostic value of negative result 75.0% and positive 76.0%, AUC 0.761; p=0.008). Conclusion. The valve macrophages of patients with IE express elevated levels of proinflammatory cytokines IL-1β and IL-6, regardless of etiological affiliation or complicated course of IE. IL-1β has a high diagnostic value for determining the inflammatory activity in IE.

Intractable complicated course of tricuspid valve infective endocarditis due to non-compliance of treatment with clinical guidelines with a decisive role of molecular biological study in etiological diagnosis: a case report

A clinical observation of the treatment non-compliance consequences with clinical guidelines and principles of empirical therapy selection in a female patient with intravenous drug abuse, viral hepatitis C and HIV infection, with a history of a COVID-19 and the development of uncontrolled staphylococcal infective endocarditis (IE) of the tricuspid valve, complicated recurrence of early prosthetic IE is presented. Successful treatment was achieved only by a combination of tricuspid valve replacement and the appointment of etiotropic therapy for S. aureus (MSSA). The typical clinical scenario was not accompanied by the choice of adequate empirical antibiotic therapy, despite the high suspicion of association with MSSA, which determined the complicated course of IE. Only the polymerase chain reaction of the heart valve tissue played a key role in the etiological diagnosis. The use of valve tissue polymerase chain reaction in addition to traditional microbiological methods is a valuable diagnostic study.

Brain abscesses in infective endocarditis: contemporary profile and neuroradiological findings.

Brain abscesses (BA) are severe lesions in the course of infective endocarditis (IE). We compare the bacteriological, clinical data, background, associated lesions, and outcome of IE patients with and without BAs, and assess the MRI characteristics of BAs. Retrospective study of 351 consecutive patients with definite IE (2005-2020) and at least one brain MRI. Patients with and without BAs were compared. Twenty patients (5.7%) had BA (80% men; median age: 44.9 ± 11.5). They were younger (p = 0.035) and had a higher rate of predisposing factors (previous IE 20% vs 2.2%, p = 0.03), intravenous drug use [25% vs 2.2%; p < 0.0001]), underlying conditions (HIV infection, 20% vs 2.2%, p < 0.0001; alcohol abuse, 20% vs 2.2% p < 0.0001]; liver disease p = 0.04; hemodialysis, p = 0.001; type 2 diabetes, p = 0.001), bacterial meningitis (p = 0.0029), rare species involvement (35% vs 7%, p < 0.0006) and extra-cerebral abscesses (p = 0.0001) compared to patients without BA. Valve vegetations were larger in Group 1 (p = 0.046). Clinical presentation could suggest the diagnosis of BA in only 7/20 (35%) patients. MR identified 58 BAs (mean/patient 2.9; range 2-12): often multiple (80%), bilateral (55%) and ≤ 10mm (72%). The presence of BA did not modify cardiac surgery indication and timing. Favorable outcome was observed in 85% of patients. Rates of predisposing, underlying conditions, rare IE agents, meningitis and metastatic abscesses are significantly higher in BA-IE patients. As BAs can develop in asymptomatic IE patients, the impact of brain MRI on their management needs thoroughly to be further investigated.

Antiphospholipid Autoantibodies and Brain Ischemic Lesions in Infective Endocarditis.

Stroke is a frequent and severe complication of infective endocarditis (IE).[1] [2] Although different factors associated with a high risk of embolic complications are known,[3] no biomarker has been identified yet. Various autoantibodies have been described in the course of IE, including antiphospholipid (aPL) autoantibodies.[4] [5] [6] Their detection at IE diagnosis may be of particular interest considering the risk of ischemic events. We aimed to determine the frequency of anticardiolipin (aCL), anti-β2GPI (aβ2GPI), antiphosphatidylethanolamine (aPE), and antiphosphatidyl/prothrombin (aPS/PT) autoantibodies in patients with IE and their association with brain ischemic events detected by systematic brain magnetic resonance imaging (MRI).

Pseudoaneurysm of the left ventricular free wall occurring after cardiac surgery of endocarditis affecting mitral and aortic valves: a case report

BackgroundInfective endocarditis remains a serious condition. Left ventricular pseudoaneurysm may complicate the clinical course of infective endocarditis or occur postoperatively.Case presentationWe describe a case of a pseudoaneurysm of the left ventricular lateral wall which developed one month following cardiac surgery of active endocarditis affecting aortic and mitral valves. The diagnosis was established by transthoracic echocardiography and computed tomography angiography of the chest. Urgent cardiac surgery is performed with excision of the pseudoaneurysm and direct closure of the defect. The patient had a complete recovery and was discharged on the twelfth postoperative day.ConclusionsLeft ventricular pseudoaneurysms are rare but potentially fatal. The symptoms revealing such complications are very diverse. Surgical treatment can be offered to younger patients.

Clinical and Echocardiographic Features of Patients With Infective Endocarditis and Bicuspid Aortic Valve According to Echocardiographic Definition of Valve Morphology

The influence of different bicuspid aortic valve (BAV) morphology in the clinical course of infective endocarditis (IE) has not yet been investigated. This study aimed to describe the clinical and echocardiographic features of IE in patients with BAV (BAVIE) according to valve morphology. Patients with definite BAVIE prospectively enrolled in 4 high-volume referral centers from 2000 to 2019 were evaluated and divided into 2 groups according to the echocardiographic definition of fused BAV morphology: right-left coronary (RL type) and right noncoronary or left noncoronary (non-RL type) cusp fusion. All patients were followed up for 1year. One hundred thirty-eight patients with BAVIE were included (77.7% male; median age, 52 [36.83-61.00]years): 112 patients with RL type (81%) and 26 patients with non-RL type BAV (19%), with no significant differences in age, sex, and comorbidities between groups. Although 43% of the cohort had known BAV, the referral was late after symptom onset, particularly for the RL phenotype; time from symptom onset to hospitalization >30days (31.3% vs 11.5%; P=.032) and New York Heart Association class≥II (64.3% vs 42.3%; P=.039) were more frequent in patients with RL type BAV than in patients with non-RL type BAV. Conversely, patients with non-RL type BAV had a higher incidence of hemorrhagic stroke (19.2% vs 5.4%; P=.034) and high-grade atrioventricular block (11.5% vs 0.9%; P=.021). Streptococcus viridans was more frequently isolated in patients with non-RL type BAV than in patients with RL type BAV (44% vs 24.1%; P=.045). No difference in short- and intermediate-term mortality was observed between groups. Clinical profile and echocardiographic features in BAVIE patients may differ according to valve morphology, and patients with BAVIE appear to be referred late, even when BAV disease is previously known.

Long-term impact of persistent vegetations at 6 month followup after treatment of infective endocarditis: a substudy of the Partial Oral vs Intravenous Antibiotic Treatment of Endocarditis (POET) tria

Abstract Background Our knowledge of changes in vegetation size throughout the course of infective endocarditis (IE) and the impact of persistent vegetations on mortality or embolization after completed antibiotic treatment is sparse. No study has previously investigated the prevalence or clinical impact of persistent vegetations on transthoracic echocardiography (TTE) at 6-months follow-up after ended IE treatment. Purpose To investigate the association between persistent vegetations at the 6-months TTE after treatment for IE and long-term prognosis as assessed in the POET trial. Methods The POET trial was a nationwide, multicenter RCT, randomizing 400 patients to either partial oral or intravenous (IV) antibiotic treatment of left-sided IE, after initial stabilization of infection using conventional IV therapy. A persistent vegetation was defined as a vegetation seen on 6-months follow-up TTE (4–7 months) after ended antibiotic treatment for IE. In the POET trial, primary outcome was defined as 1) all-cause mortality, 2) unplanned cardiac surgery, 3) embolic events or 4) relapse of bacteremia, in the 5-year follow-up period. Patients without TTE due to death or lack of available TTE were excluded. Results Out of 400 patients, 20 were excluded due to death during 6-months follow-up, and 201 were excluded due to unavailable TTE, leaving 179 TTEs for analysis. At 6-months follow-up, a persistent vegetation was seen in 30 patients (16.7%, 21 males (70%), mean age 69.6 years (SD 7.7)) (Table 1). Seventeen patients (56.7%) had a persistent vegetation on the aortic valve and 13 patients (43.3%) on the mitral valve. More patients without a persistent vegetation had undergone initial surgical treatment of IE than those with a vegetation (57.7 vs 23.3%, p=0.001). In all surgically treated patients with persistent vegetation at 6-months follow-up, the vegetation was found on another valve than the operated valve. The composite primary outcome from 6-months follow-up and until 5-year follow-up occurred in 8 patients (26.7%) with a persistent vegetation, compared to 38 patients (25.5%) (p=1.00) without. (Table 2) In patients randomized for peroral treatment, no significant difference in prevalence of persistent vegetation was found (15 patients (50%) with persistent vegetations vs. 74 patients (49.7%) without, p=1.00). Conclusion The occurrence of persistent vegetations at 6 months follow-up was 16.7%. There was no association between persistent vegetations at 6-months follow-up and the occurrence of the primary outcome after 5 years follow-up, suggesting that the risk associated with residual vegetations after end of antibiotic treatment is negligible after 6-months. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

Implications of the healthcare pathway in infective endocarditis: beginning to see what we do not know.

Despite improvements in diagnosis and treatment, and compared with other cardiovascular diseases, mortality from infective endocarditis (IE) has not dramatically declined.1,2 The reasons are numerous and, from an epidemiological perspective, include changing pathogens and patients.3,4 However, given the heterogeneity of presentations and seemingly disparate organ involvement, treatment of endocarditis has been perennially humbling.5 Accordingly, collaboration across subspecialties is essential to improve recognition and implementation of best practices.6 In this setting, optimal application of healthcare pathways within a multidisciplinary IE team might also substantially improve outcomes, though is admittedly difficult to quantify given the varied course of IE. In the current manuscript, Florent et al.7 have provided further insights into the potential advantages of dedicated healthcare pathways in the management and prognosis of patients with IE. Importantly, the authors have included an in-depth analysis of a population where few data are available—patients who are treated exclusively in community-based non-referral centres. In a contemporary, prospective multicentre cohort study of over 300 patients, Florent et al. categorized patients into three groups: those treated only in a referral centre, those transferred to a referral centre, and those treated exclusively in a non-referral centre. Among these groups, the aims were two-fold and included assessing all-cause mortality at 1 year and the implementation of European Society of Cardiology (ESC) IE Guidelines.8

The Clinical Course of Infective Endocarditis and Independent Predictors of In-Hospital Mortality

Introduction: Despite advances in prevention, medical, and surgical treatment, the global prevalence of infective endocarditis (IE) has been gradually rising over the last two decades. However, the profile of IE varies by continent, geographic region, and hospital type. In this study, we aimed to investigate the epidemiological and clinical features of IE and to determine the factors predicting in-hospital mortality. Patients and Methods: This retrospective study was carried out at a single tertiary health care hospital in Türkiye. A total of 104 consecutive patients (&gt;18 years old) who were hospitalized with IE between January 2016 and August 2021 were included. Modified Duke criteria were used to diagnose IE. Demographic information (age and gender), underlying heart diseases, comorbidities, causative microorganisms, blood culture results, echocardiographic findings, cardiac and extracardiac complications, surgical requirements, and in-hospital mortality were all examined. Results: The study included 104 IE cases (mean age: 57.2 ± 15.9 years; 59.6% males). Fifty-six patients (53.9%) had native valve IE, 37 patients (35.6%) had prosthetic valve IE, and four patients (3.8%) had devicerelated IE. Blood cultures were negative in 62 cases (59.6%). Staphylococcus aureus was the most common responsible microorganism in 17 patients [methicillin-sensitive Staphylococcus aureus in 13 (12.5%), methicillin-resistant Staphylococcus in four (3.8%)]. The overall in-hospital mortality rate was 30.8%. White blood cell count (OR= 1.002, 95% CI= 1.001-1.003) creatinine (OR= 1.45, 95% CI= 1.08-2.00), acute renal failure (OR= 8.60, 95% CI= 2.27-37.81), and cerebrovascular accidents (OR= 4.58, 95% CI= 1.21-18.85) were independent predictors of in-hospital mortality. Conclusion: In line with developed countries, the epidemiology and causative pathogens of IE in Türkiye have been changing. Investigating these epidemiological and clinical changes may serve as a basis for strategies to be developed for the prevention and treatment of IE.

Cytokine markers of clinical variants of infective endocarditis

Introduction. Infective endocarditis is a bacterial disease. Pathogen is localized mainly on heart valves and endocardium. This condition is accompanied by immunopathological manifestations and potential generation of septic process being unfavorable prognosis for disease outcome. Currently, the causes of death of patients with endocarditis have been increasingly presented as thromboembolic complications, which severity depends on variant of the disease course. An important role in imbalanced immune system in the infectious process is assigned to altered intercellular interaction mediated via cytokine network. Activated immune cells produce cytokines, which investigating is important in terms of interpreting changes in immune system functionality, assessing the severity of diseases and controlling therapeutic effectiveness. Infective endocarditis remains a severe disease associated with high mortality despite current advances in diagnostics and treatment. A timely diagnostic process and early initiation of treatment are major factors for successful patient management necessitating to improve diagnostics of various clinical variants of endocarditis course, taking into account pathogenetically relevant cytokines. Objective was to comparatively evaluate the importance of serum cytokine concentrations in patients with uncomplicated course of infective endocarditis and its thromboembolic complications and determine cytokine markers of various variants of endocarditis course. Materials and methods. An immunological examination of 119 blood serum samples from patients with confirmed diagnosis of infectious endocarditis and 20 samples from apparently healthy persons was carried out. Depending on the clinical disease form, the patients were divided into 4 groups: group 1 primary infective endocarditis (PIE) with thromboembolic complications (n = 24), 2 PIE without thromboembolic complications (n = 34), 3 secondary IE with thromboembolic complications (n = 27), 4 secondary IE without thromboembolic complications (n = 34). The control group consisted of 20 apparently healthy subjects. Immunological studies of serum cytokine concentrations were conducted in all groups. Results. Statistically significant increase in serum concentration of IL-10, IL-6, VEGF-A, IL-18, IL-1Ra and IL-8 was revealed in all clinical groups of patients compared to those in control group (p 0,05). By correlation analysis, we found a significant positive relationship between IL-10 and IL-18 or IL-6. An increase in the concentration of IL-10 leads to increased level of pro-inflammatory IL-18 and IL-6. The marker of secondary endocarditis was observed as increased level of serum concentrations of IFN. A characteristic feature of primary infective endocarditis with thromboembolic complications was revealed as significantly increased serum concentration of IL-8, IL-1Ra and IL-6. Markers of secondary complicated endocarditis were identified as increased level of IL-6, VEGF-A and IL-18.

Infective endocarditis in patients with diabetes

Diabetes mellitus (DM) is an adverse premorbid background for the development, course and outcome of infective endocarditis (IE), and therefore the combination of these diseases requires study. Objective: to study the clinical features and outcomes of infective endocarditis in patients with diabetes mellitus. Material and methods A retrospective (from 2001 to 2007) and a prospective (from 2008 to 2018) analysis of 347 patients with specifi c IE, 243 men and 104 women, aged from 17 to 83 (median age 44.8; 34–54). Results. 22 patients with IE, were diagnosed with diabetes, that is, the incidence of this pathology was 6.3%. Type 1 diabetes was observed in 7 (2% of the total number of patients and 32% among patients with a combination of IE and diabetes). Type 2 diabetes was diagnosed in 15 patients (4.3% and 68%, respectively). In subgroups of patients with IE and diabetes and without it, statistically signifi cant diff erences in age (p &lt; 0.05), Charlson comorbidity index (p &lt; 0.001), incidence of neurological complications ((p &lt; 0.05), hospital mortality (p &lt; 0.05) were noted, while patients with IE on the background of type 1 diabetes, had a more severe course of the disease. According to key characteristics of the pathological process in IE, localization, severity of systemic infl ammation, clinical and biochemical parameters, no signifi cant diff erences in the studied groups were found. Findings. The obtained results confi rm the literature data on fundamentally identical regularities of the course of IE in patients with and without diabetes. At the same time, the development of IE on the background of diabetes is a prognostically unfavorable combination of comorbid conditions, which requires special attention of physicians to such a contingent of patients, interaction of specialists for their successful management.

Enterococcus gallinarum causing cervical vertebral osteomyelitis: Imagery detecting the process of rapid progression of degeneration-like change in 3 months.

We present a series of images of X-rays and MRI of vertebral osteomyelitis caused by Enterococcus gallinarum in a 65-year-old patient with persistent neck pain and fever accompanied by preceding transient biliary enzymes elevation. Images detected progression of degeneration-like changes of C5-7 in three months, which is too rapid for true degeneration and relatively slow for vertebral osteomyelitis of common pathogens. Though initial imagery evaluation detected merely degenerative change, the patient was followed up monthly because of persistent fever. Three months later, the images detected the typical imagery of vertebral osteomyelitis i.e., the destruction of vertebral bone: narrowing of intervertebral spaces with focal osteosclerosis and osteolysis on C5-7 became prominent. At this point, consultation to general internal medicine was made. With grade 3 regurgitation murmur, transthoracic echocardiography was performed and revealed 14-mm-in-diameter vegetation on aortic valve. Blood cultures detected Enterococcus gallinarum of which suspected entry was biliary tract. No previous case reports of Enterococcus gallinarum referred to vertebral osteomyelitis. While this case showed a typical clinical course of infective endocarditis, the course of progression of vertebral osteomyelitis and perhaps endocarditis was much slower comparing to common pathogens. This might reflect the relatively non-life-threatening features of this organism. Enterococcus gallinarum shows mild resistance to vancomycin and cephalosporins, initial therapy sometimes fails. Enterococcus gallinarum should be newly added to pathogenic candidates of vertebral osteomyelitis especially when feverish patients shows back or neck pain with preceding biliary tract problems.

Course of Disease and Clinical Outcome of Infective Endocarditis in HIV-infected Individuals: A Systematic Review and Meta-analysis.

Infective endocarditis (IE) causes substantial morbidity and mortality if untreated. The clinical course of IE might be different in HIV-positive patients as a result of immune dysfunction. This systematic review investigates the clinical course of IE in HIV-positive compared to HIV-negative patients. A systematic search was performed in PubMed, EMBASE, and Cochrane Library and registered in PROSPERO (CRD42016048649). All articles from 1996 and onward addressing the clinical outcome of HIV-positive adults suffering from IE were reviewed and included based on predefined inclusion and exclusion criteria. A meta-analysis was performed for the outcome mortality. Twenty-three articles were included of which eight included HIVpositive patients only, and 15 compared HIV-positive to HIV-negative patients. Two studies included patients on antiretroviral therapy (ART). HIV and intravenous drug use (IVDU) were closely related. Mortality was higher in HIV-positive patients with a CD4 count below 200 cells/μl than in HIV-positive patients with a higher CD4 count, while mortality was similar for HIV-positive compared to HIV-negative patients (risk ratio = 0.86 [95% confidence interval: 0.53-1.40]). No difference was found in length of hospital stay or rehospitalization. Clinical outcomes were strongly related to the right- or left-sided endocarditis. The clinical course of IE is not different for patients with and without HIV. Clinical outcomes were mainly associated with other factors, such as IVDU and side of cardiac involvement, rather than HIV status.

Evolution of antimicrobial resistance and mortality in Staphylococcus aureus endocarditis during 15 years in a university hospital

RESUMENIntroducciónUno de los microorganismos más agresivos en la endocarditis infecciosa (EI) es Staphylococcus aureus. Analizamos la resistencia de S. aureus a los antibióticos y su repercusión en el curso clínico de la EI en un periodo reciente de 15 años.Material y métodosEstudio retrospectivo de los pacientes diagnosticados de EI en un hospital universitario desde 2005 hasta 2019. Análisis bivariado y multivariado de la grave-dad al ingreso, comorbilidades, concentraciones mínimas inhibitorias (CMI) y mortalidad.ResultadosDe los 293 casos de EI, 66 (22,5%) fueron por S. aureus, y 21 (7,2%) eran S. aureus resistentes a meticilina (SARM). La prevalencia de cepas con CMI a vancomicina ≥ 1mg/L pasó del 4,8% al 63,6% (p< 0,001) y los casos de SARM de un 38 a un 27,3% (p=0,45). Una mayor edad (p=0,02), comorbilidad (p<0,01) y origen nosohusial (p=0,01) fueron factores asociados a SARM. Pero la resistencia antimicrobiana y la gravedad al ingreso no se asociaron al exitus; sí lo hicieron la EI de localización derecha (OR= 0,08; IC 95%: 0,01-0,51), comorbilidades (OR por punto del índice de Charlson = 1,30; IC 95%: 1,01-1,69) y creatinina al ingreso (OR por mg/dL= 1,56; IC 95%= 1,01-2,35; p= 0,04).ConclusiónHemos experimentado un incremento de casos de EI con CMI a vancomicina ≥ 1mg/L, sin variación significativa en infecciones por SARM. La resistencia antimicrobiana no se asoció a mortalidad. Si lo hicieron la comorbilidad y la afectación izquierda.

Mitral Valve Endocarditis in a Pediatric Patient: When Is the Right Time to Intervene? A Case Report

Infective endocarditis (IE) is most often treated conservatively with medical management. There are no clear guidelines in the pediatric population for timing of surgical intervention. This is a case report of an 18-month-old male admitted to the hospital with IE. His workup showed a large vegetation on the mitral valve with evolving regurgitation caused by Kingella kingae, a HACEK group organism. Factors that led to consideration for early surgical intervention included the size of the vegetation (19 mm), the etiologic agent (K. kingae) described to be associated with a high rate of complications, the absence of neurologic complications, and the possibility for valve-sparing repair strategies. Following mitral valve repair, the patient made an uneventful recovery and he was discharged home within a week, to complete a course of antibiotics. Surgical intervention early in the disease course of IE can be a safe option and could pre-empt the development of embolic complications especially in the setting of very large vegetations and certain types of high-risk organisms. Additionally, early surgery allows for valve repair and could avoid valve replacement with its attendant risk of anticoagulation therapy and future surgery.

P627 Step by step valve destruction in infective endocarditis with no apparent vegetations

Abstract Background Infective endocarditis can present without evident vegetation, diagnosis is challenging and prognosis very poor. We present an illustrative case where natural evolution of the mitral valve destruction with no evident vegetations was followed with frequent consecutive transthoracic (TTE) and transesophageal echocardiography (TOE). Case presentation 71-year old male with known dilated cardiomyopathy presented with dyspnoea, ankle swelling and severe kidney failure with hyperkalemia. During short hospitalization he was recompensated with haemodialysis, parenteral diuretics and inotropes. TTE showed dilated left ventricle with severe systolic dysfunction and no evidence of valvular disease. Few days after discharge he was readmitted with malaise and febrile state with no obvious site of infection. Blood cultures were positive for Staphylococcus aureus and antibiotic therapy was initiated immediately. Weekly TTEs and TOEs were performed (Figure 1, column A-D): Week 1: TTE was performed due to congestive heart failure. There was no suspicion on disease and TTE showed no obvious mitral valve pathology. Week 3: Second TTE showed only light thickening of posterior mitral leaflet with mild mitral regurgitation. Week 4: Follow-up TOE was performed showing posterior leaflet discontinuity with small eccentric regurgitation jet and no vegetation. Week 6: Symptoms of congestive heart failure persisted despite antibiotic treatment. A progressive destruction of posterior leaflet with evident perforation of P1 scallop and consequent severe mitral regurgitation. Patient was referred for urgent mitral valve replacement. Conclusions Staphylococcus aureus is a destructive pathogen and can cause severe destruction of native valve even without obvious vegetations. This case presents echocardiographic features of natural course of infective endocarditis on mitral valve. Despite antibiotic therapy progressive valve destruction is possible. Abstract P627 Figure.

Actinomyces neuii: a case report of a rare cause of acute infective endocarditis and literature review

BackgroundInfective endocarditis caused by Actinomyces spp. is extremely rare. However, cases by new species of Actinomyces have been increasingly reported due to advances in laboratory techniques, and many of these species do not cause classic presentations of actinomycosis. Actinomyces neuii is reported to have a tendency to cause endovascular infection. The course of infective endocarditis caused by Actinomyces spp. is usually indolent.Case presentationA 61-year-old man with history of infective endocarditis, end stage renal disease, and monoclonal gammopathy was admitted for an abrupt fever, confusion, dysarthria, and facial droop after hemodialysis. Echocardiogram showed vegetations on both the aortic and mitral valves. Two sets of blood culture grew A. neuii. Brain MRI showed multiple bilateral cerebral infarcts consistent with septic emboli. The patient recovered after valvular surgery and prolonged intravenous and oral antibiotic therapy.ConclusionsThis case illustrates an unusually acute presentation of A. neuii infective endocarditis. As with other Gram-positive bacilli, Actinomyces spp. isolates are often regarded as a result of contamination. One should keep it in mind as a cause of infective endocarditis in vulnerable patient populations.

Czynniki ryzyka śmiertelności w infekcyjnym zapaleniu wsierdzia — doświadczenia jednego ośrodka

Introduction. Infective endocarditis (IE) is a disease associated with high morbidity and mortality. Multiple risk factors have been identified for mortality in IE. Material and methods. 21 patients diagnosed with IE between January 2018 and January 2019 were retrospectively analysed. All data was expressed as mean ± standard error (SE). Variables were analysed with chi-square, Fisher’s exact, and Mann-Whitney tests. A p-value Results. Total mortality was 52.4% and in-hospital mortality was 28.6%. Patients who died in the course of IE were older compared to survivors (66.7 ± 19.8 years vs 70.8 ± 11.6). Staphylococci and Streptococci spp. were causative patho- gens in 71.4% of cases of IE. Morphology was the most important feature that identified patients who died: white blood cells were higher in non-survivors (35.39 ± 14.36 vs 12.02 ± 4.67, p Conclusion. Morphology is recommended as the key diagnostic test in predicting mortality risk in patients with IE. The plates-to-leucocytes ratio is also a significant marker of mortality. Prompt identification and close monitoring of risk factors may prevent a higher mortality rate in IE.