Definite Endocarditis Research Articles

Evaluating the Duke Criteria for infectious endocarditis in a single-center retrospective study

The Duke Criteria have shaped the way infectious endocarditis (IE) is diagnosed in the last 30 years. This study aims to evaluate their current validity and importance in the diagnostic of IE. A retrospective cohort study was conducted on 163 consecutive patients who presented at the University Hospital in Ulm (Germany) with clinical suspicion of IE between 2009 and 2019. With patients’ medical records we differentiated between definitive endocarditis (DIE), possible endocarditis (PIE) and rejected endocarditis (RIE) and assessed the validity of the Duke Criteria in comparison to the final discharge diagnosis. We then tried to identify new potential parameters as an addition to the current valid Duke Criteria. The validity of the Duke Criteria improves with the length of hospitalization (especially cardiac imaging criterion, RIE 33.3%, PIE 31.6% and DIE 41.9%, p = 0.622 at admission and RIE 53.3%, PIE 68.4%, DIE 92.2%, p < 0.001 at discharge). At admission, overall sensitivity and specificity were respectively 29.5 and 91.2% in the DIE group. At discharge, sensitivity in the DIE group rose to 77.5% and specificity decreased to 79.4%. Of all screened metrics, microhematuria (p = 0.124), leukocyturia, (p = 0.075), younger age (p = 0.042) and the lack of rheumatoid disease (p = 0.011) showed a difference in incidence (p < 0.2) when comparing DIE and RIE group. In multivariate regression only microhematuria qualified as a potential sixth minor criterion at admission. Even with the latest technological breakthroughs our findings suggest that the Duke Criteria continue to hold value in the accurate assessment of IE. Future efforts must shorten the time until diagnosis.

In Which Patients Do the 2023 Duke-ISCVID Criteria for Infective Endocarditis Increase the Diagnosis of "Definite Endocarditis"?-A Preliminary Analysis in the Prospectively Evaluated DERIVE Cohort.

Background/Objectives: Recently, an update of the Duke criteria for the diagnosis of infectious endocarditis has been published: the 2023 Duke-ISCVID criteria. To gain an insight into which proportion of patients are affected by the new criteria, and which criteria might be the most relevant for the expected increase in sensitivity, we analysed data from a registry of cardiovascular infections. Methods: The 2023 Duke-ISCVID criteria were applied to patients who were diagnosed with and treated for endocarditis after having been classified as "possible" endocarditis according to the 2015 ESC Modified Duke criteria. In patients thus newly classified as "definite endocarditis", diagnostic factors leading to this reclassification were described. Results: Of 397 patients, 48 (12%) did not fulfil the definition "definite infectious endocarditis" according to the 2015 ESC Modified Duke criteria. Of these, six (13%) fulfilled the definition when the 2023 Duke-ISCVID criteria were applied. A main factor triggering this reclassification was the consideration of microorganisms identified using valve PCR. Conclusions: As expected, the sensitivity of the new 2023 Duke-ISCVID criteria is increased in this cohort, mainly through the incorporation of new diagnostic methods in the criteria. Further studies are required to assess the effect on specificity in detail.

Clinical features and prognosis of prosthetic valve endocarditis due to Staphylococcus aureus.

Staphylococcus aureus prosthetic valve endocarditis (SAPVE) is a serious infection with high mortality. The main objective of this study was to identify factors associated with in-hospital mortality. From January 2008 to December 2021, consecutive patients from a Spanish cohort of infective endocarditis with a definitive diagnosis of SAPVE were analyzed. During the study period, 219 cases of definitive SAPVE were diagnosed, which accounted for 16.7% of a total of 1309 cases of definitive prosthetic valve endocarditis (PVE). Patients presented advanced age and marked comorbidity. There was a higher incidence of persistent bacteremia, septic shock, stroke, and acute kidney injury than in cases of PVE caused by other microorganisms. Methicillin resistance was not associated with differences in clinical presentation, echocardiographic findings, or mortality. Only 50.6% of the patients with surgical indications (88 patients) underwent surgery. Overall, in-hospital mortality was 47.9%. The variables associated with in-hospital mortality were age (OR:1.03, 95% CI: 1.00-1.05; p = 0.016), heart failure (OR:2.86, 95% CI: 1.53-5.32; p = 0.001), acute kidney injury (OR:2.42, 95%CI:1.28-4.58; p = 0.006), stroke (OR:3.53, 95%CI:1.79-6.96; p < 0.001) and surgery indicated but not performed (OR:2.01, 95%CI:1.06-3.8; p = 0.030). On the other hand, the performance of surgery per se in patients with SAPVE, regardless of whether there was a surgical indication according to the guidelines, was not associated with a reduction in in-hospital mortality. SAPVE is characterized by high mortality, which is more marked in patients who present a surgical indication but do not undergo surgery.

Identifying risk factors for blood culture negative infective endocarditis: An international ID-IRI study

BackgroundBlood culture-negative endocarditis (BCNE) is a diagnostic challenge, therefore our objective was to pinpoint high-risk cohorts for BCNE. MethodsThe study included adult patients with definite endocarditis. Data were collected via the Infectious Diseases International Research Initiative (ID-IRI). The study analysing one of the largest case series ever reported was conducted across 41 centers in 13 countries. We analysed the database to determine the predictors of BCNE using univariate and logistic regression analyses. ResultsBlood cultures were negative in 101 (11.65 %) of 867 patients. We disclosed that as patients age, the likelihood of a negative blood culture significantly decreases (OR 0.975, 95 % CI 0.963–0.987, p < 0.001). Additionally, factors such as rheumatic heart disease (OR 2.036, 95 % CI 0.970–4.276, p = 0.049), aortic stenosis (OR 3.066, 95 % CI 1.564–6.010, p = 0.001), mitral regurgitation (OR 1.693, 95 % CI 1.012–2.833, p = 0.045), and prosthetic valves (OR 2.539, 95 % CI 1.599–4.031, p < 0.001) are associated with higher likelihoods of negative blood cultures. Our model can predict whether a patient falls into the culture-negative or culture-positive groups with a threshold of 0.104 (AUC±SE = 0.707 ± 0.027). The final model demonstrates a sensitivity of 70.3 % and a specificity of 57.0 %. ConclusionCaution should be exercised when diagnosing endocarditis in patients with concurrent cardiac disorders, particularly in younger cases.

Effectiveness and safety of cefazolin versus cloxacillin in endocarditis due to methicillin-susceptible Staphylococcus spp.: a multicenter propensity weighted cohort study.

To compare the effectiveness and safety of cefazolin versus cloxacillin for the treatment of infective endocarditis (IE) due to methicillin-sensitive Staphylococci (MSS). Data were retrospectively collected on patients treated for a definite MSS endocarditis who received cefazolin or cloxacillin for at least 10 consecutive days in six French hospitals between January-1 2014 and December-31 2020. The primary endpoint was treatment failure defined as a composite of death within 90 days of starting antibiotherapy, or embolic event during antibiotherapy, or relapse of IE within 90 days of stopping antibiotherapy. We used Cox regression adjusted for the inverse probability of treatment weighting of receiving cefazolin. 192 patients were included (median age 67.8 years). IE was caused by S.aureus in 175 (91.1%) and by coagulase-negative staphylococci in 17 (8.9%). Ninety-four patients (48.9%) received cefazolin, and 98 (51%) received cloxacillin. 34 patients (34.7%) with cefazolin and 26 (27.7%) with cloxacillin met the composite primary endpoint, with no significant differences between groups (adjusted HR = 1.13, 95% CI 0.63 to 2.03). There were no significant differences in secondary efficacy endpoints or biological safety events. The effectiveness of cefazolin did not significantly differ from cloxacillin for the treatment of MSS endocarditis.

Staphylococcus aureus bacteraemia, cardiac implantable electronic device, extraction, and the risk of recurrent infection; a retrospective population-based cohort study

Background Patients with cardiac implantable electronic device (CIED) and Staphylococcus aureus bacteraemia (SAB) are at risk of having CIED infection, pocket infection or endocarditis. To avoid treatment failures, guidelines recommend that the CIED should be extracted in all cases of SAB butrecent studies indicate low extraction rates and low risk of relapse. The aim of the study was to describe a Swedish population-based cohort of patients with CIED and SAB, the rate of extraction, and treatment failure measured as recurrent SAB. Methods Patients identified to have SAB in the Karolinska Laboratory database, serving a population of 1.9 million, from January 2015 through December 2019 were matched to the Swedish ICD and Pacemaker Registry. Patients with CIED and SAB were included. Clinical data were collected from medical records. Results A cohort of 274 patients was identified and 38 patients (14%)had the CIED extracted. Factors associated with extraction were lower age, lower Charlson comorbidity index, shorter time since CIED implantation, and non-nosocomial acquisition, but not mortality. No patient was put on lifelong antibiotic treatment. Sixteen patients (6%) had a recurrent SAB within one year, two in patients subjected to extraction (5%) and 14 in patients not subjected to CIED-extraction (6%). Three of the 14 patients were found to have definite endocarditis during the recurrent episode. Conclusions Despite a low extraction rate, there were few recurrences. We suggest that extraction of the CIED might be omitted if pocket infection, changes on the CIED, or definite endocarditis are not detected.

Evaluation of the Specificity of the 2023 Duke-International Society of Cardiovascular Infectious Diseases Classification for Infective Endocarditis.

The 2023 Duke-ISCVID (International Society of Cardiovascular Infectious Diseases) classification is a new diagnostic tool for infective endocarditis, updating the 2000 modified Duke and the 2015 European Society for Cardiology (ESC) classifications. In comparison, its sensitivity is higher; however, its specificity remains to be evaluated and compared to that of the 2 other classifications in endocarditis suspected patients. We retrospectively collected the characteristics of patients hospitalized in Bichat University's Hospital, Paris, in 2021, who had been evaluated for clinical suspicion of endocarditis, have had at least a transthoracic echocardiography, 2 pairs of blood cultures, 3-month follow-up and in whom endocarditis diagnosis was finally rejected. All patients were classified by 2000 modified Duke, 2015 ESC and 2023 Duke-ISCVID, as though the endocarditis diagnosis had not been rejected. In total, 130 patients' charts were analyzed. Mean age was 62 years, 84 (64.6%) were male, 39 (30.0%) had prosthetic cardiac valve or valve repair, 21 (16.2%) cardiac implanted electronic device, and 30 (23.1%) other cardiac conditions. Overall, 5, 2, and 5 patients were falsely classified as definite endocarditis with the 2000 modified Duke, 2015 ESC, and 2023 Duke-ISCVID classifications, respectively. The corresponding specificities were 96.2% (95% confidence interval [CI] [90.8%, 98.6%]), 98.5% (95% CI [93.9%, 99.7%]), and 96.2% (95% CI [90.8%, 98.6%]). The rates of possible endocarditis were of 38%, 35%, and 35% in the 3 classifications, respectively. The 2023 Duke-ISCVID classification is highly specific for ruling out the diagnosis of definite infective endocarditis in patients who had been evaluated for IE.

Three Years’ Experience of the Infective Endocarditis Team in a University Hospital

Objective: Infective endocarditis is a serious disease with high morbidity and mortality due to serious embolic complications. The follow-up of the patients requires multidisciplinary evaluation. We aimed to share the experience of the infective endocarditis team in our hospital and to guide the work of the teams to be formed in the future. Methods: Our study was planned as descriptive, cross-sectional, and observational. The patients were diagnosed by the modified Duke criteria. The National Infective Endocarditis Consensus Report was considered during the diagnosis, follow-up, and treatment process. Results: Fifty (45.4%) of 110 patients followed by the team were diagnosed with endocarditis. Thirty of the patients (51.8%) were male, the median age was 63.5 (18-87) days, and the median duration of symptoms was 35.7 (1-180) days. 76% of the diagnoses were definite endocarditis, 46% of the cases had an acute course, aortic valve involvement was 38%, and native valve involvement was 60%; the most isolated agent was Stapyhylococcus aureus. Community-acquired infection was 46%. The most common predisposing factors were prosthetic heart valve (38%) and hemodialysis (46%). Fever was observed in 64% of the patients and dyspnea in 58%. The rate of detection of vegetation by transesophageal echocardiography was 68%. Brain, pulmonary embolisms, and spondylodiscitis were the most common complications. The median time for blood culture to become negative was 3 (3-15) days, the operation time for 15 patients was 8 (1-30) days, and the 30-day hospital mortality was 28%. A statistically significant correlation was found between mortality and the presence of previous endocarditis, ejection fraction below 50%, complication development, hospitalization in the intensive care unit, presence of thrombocytopenia, Charlson comorbidity index ≥5, and vegetation size ≥1 cm (p&lt;0.05). We determined that the presence of previous endocarditis increased the risk of mortality 14 times (p=0.025). Conclusion: Mortality and morbidity rates can be reduced by detecting underlying diseases, controlling complications, applying early effective antibiotic and anticoagulant treatment, surgical interventions at the right time, and rapid supportive treatments for sepsis by teams formed with a multidisciplinary approach.

Clinical Characteristics and Outcomes of Patients With Cutibacterium acnes Endocarditis

It is suggested that patients with Cutibacterium acnes endocarditis often present without fever or abnormal inflammatory markers. However, no study has yet confirmed this statement. To assess the clinical characteristics and outcomes of patients with C acnes endocarditis. A case series of 105 patients presenting to 7 hospitals in the Netherlands and France (4 university hospitals and 3 teaching hospitals) with definite endocarditis according to the modified Duke criteria between January 1, 2010, and December 31, 2020, was performed. Clinical characteristics and outcomes were retrieved from medical records. Cases were identified by blood or valve and prosthesis cultures positive for C acnes, retrieved from the medical microbiology databases. Infected pacemaker or internal cardioverter defibrillator lead cases were excluded. Statistical analysis was performed in November 2022. Main outcomes included symptoms at presentation, presence of prosthetic valve endocarditis, laboratory test results at presentation, time to positive results of blood cultures, 30-day and 1-year mortality rates, type of treatment (conservative or surgical), and endocarditis relapse rates. A total of 105 patients (mean [SD] age, 61.1 [13.9] years; 96 men [91.4%]; 93 patients [88.6%] with prosthetic valve endocarditis) were identified and included. Seventy patients (66.7%) did not experience fever prior to hospital admission, nor was it present at hospitalization. The median C-reactive protein level was 3.6 mg/dL (IQR, 1.2-7.5 mg/dL), and the median leukocyte count was 10.0 × 103/µL (IQR, 8.2-12.2 × 103/µL). The median time to positive blood culture results was 7 days (IQR, 6-9 days). Surgery or reoperation was indicated for 88 patients and performed for 80 patients. Not performing the indicated surgical procedure was associated with high mortality rates. Seventeen patients were treated conservatively, in accordance with the European Society of Cardiology guideline; these patients showed relatively high rates of endocarditis recurrence (5 of 17 [29.4%]). This case series suggests that C acnes endocarditis was seen predominantly among male patients with prosthetic heart valves. Diagnosing C acnes endocarditis is difficult due to its atypical presentation, with frequent absence of fever and inflammatory markers. The prolonged time to positivity of blood culture results further delays the diagnostic process. Not performing a surgical procedure when indicated seems to be associated with higher mortality rates. For prosthetic valve endocarditis with small vegetations, there should be a low threshold for surgery because this group seems prone to endocarditis recurrence.

Impact of Intermediate Susceptibility to Penicillin on Antimicrobial Treatment and Outcomes of Endocarditis Caused by Viridans and Gallolyticus Group Streptococci.

Evidence supporting combination treatment with a beta-lactam plus an aminoglycoside (C-BA) for endocarditis caused by viridans and gallolyticus group streptococci (VGS-GGS) with intermediate susceptibility to penicillin (PENI-I) is lacking. We assessed the clinical characteristics and outcomes of PEN-I VGS-GGS endocarditis and compared the effectiveness and safety of C-BA with third-generation cephalosporin monotherapy. Retrospective analysis of prospectively collected data of a cohort of definite endocarditis caused by penicillin-susceptible and PENI-I VGS-GGS (penicillin minimum inhibitory concentration ranging from 0.25 to 2 mg/L) between 2008 and 2018 in 40 Spanish hospitals. We compared cases treated with monotherapy or with C-BA and performed multivariable analyses of risk factors for in-hospital and 1-year mortality. A total of 914 consecutive cases of definite endocarditis caused by VGS-GGS with complete or intermediate susceptibility to penicillin were included. A total of 688 (75.3%) were susceptible to penicillin and 226 (24.7%) were PENI-I. Monotherapy was used in 415 (45.4%) cases (cephalosporin in 331 cases) and 499 (54.6%) cases received C-BA. In-hospital mortality was 11.9%, and 190 (20.9%) patients developed acute kidney injury. Heart failure (odds ratio [OR]: 6.06; 95% confidence interval [CI]: 1.37-26.87; P = .018), central nervous system emboli (OR: 9.83; 95% CI: 2.17-44.49; P = .003) and intracardiac abscess (OR: 13.47; 95% CI: 2.24-81.08; P = .004) were independently associated with in-hospital mortality among PEN-I VGS-GGS cases, while monotherapy was not (OR: 1.01; 95% CI: .26-3.96; P = .982). Our findings support the use of cephalosporin monotherapy in PEN-I VGS-GGS endocarditis in order to avoid nephrotoxicity without adversely affecting patient outcomes.

Changing Trends in Demographics, Risk Factors, and Clinical Features of Patients With Infective Endocarditis-Related Stroke, 2005-2015.

There is a rising incidence of infective endocarditis-related stroke (IERS) in the United States attributed to the opioid epidemic. A contemporary epidemiologic description is necessary to understand the impact of the opioid epidemic on clinical characteristics of IERS. We describe and analyze trends in the demographics, risk factors, and clinical features of IERS. This is a retrospective cohort study within a biracial population of 1.3 million in the Greater Cincinnati/Northern Kentucky region. All hospitalized patients with hemorrhagic or ischemic stroke were identified and physician verified from the 2005, 2010, and 2015 calendar years using ICD-9 and ICD-10 codes. IERS was defined as an acute stroke attributed to infective endocarditis meeting modified Duke Criteria for possible or definite endocarditis. Unadjusted comparison of demographics, risk factors, outcome, and clinical characteristics was performed between each study period for IERS and non-IERS. An adjusted model to compare trends used the Cochran-Armitage test for categorical variables and a general linear model or Kruskal-Wallis test for numerical variables. Examination for interaction of endocarditis status in trends was performed using a general linear or logistic model. A total of 54 patients with IERS and 8,204 without IERS were identified during the study periods. Between 2005 and 2015, there was a decline in rates of hypertension (91.7% vs 36.0%; p = 0.0005) and increased intravenous drug users (8.3% vs 44.0%; p = 0.02) in the IERS cohort. The remainder of the stroke population demonstrated a significant rise in hypertension, diabetes, atrial fibrillation, and perioperative stroke. Infective endocarditis status significantly interacted with the trend in hypertension prevalence (p = 0.001). From 2005 to 2015, IERS was increasingly associated with intravenous drug use and fewer risk factors, specifically hypertension. These trends likely reflect the demographics of the opioid epidemic, which has affected younger patients with fewer comorbidities.

A retrospective analysis of blood culture-negative endocarditis at a tertiary care centre in Switzerland

Numerous studies from different countries have contributed to an improved understanding of blood culture-negative infective endocarditis. However, little is known about its epidemiology and microbiology in Switzerland. We aimed to assess the epidemiology and microbiology of blood culture-negative endocarditis at the University Hospital Zurich, Switzerland. We screened all patients hospitalised between 1997 and 2020 with possible or definite endocarditis at our institution. Thereof, we identified all cases with blood culture-negative endocarditis and retrospectively retrieved patient characteristics, microbiological, histopathological, radiographicand surgical data from medical records. Among 861 patients screened, 66 (7.7%) cases of blood culture-negative endocarditis were identified. Thereof, 31 cases could be microbiologically documented or not documented (n = 30), and in five cases a non-infectious aetiology was confirmed. Endocarditis predominantly affected men (77%) and the left heart (79%);predisposing factors were prosthetic valves (42%), congenital heart disease (35%) and prior endocarditis (14%). The most common reasons for negative blood cultures were antibiotic treatment prior to blood culture sampling (35%), fastidious and slow growing microorganisms (30%) and definite non-infective endocarditis (8%). Coxiella burnetii and Bartonella spp. were the most common fastidious bacteria identified. In addition to serology, identification of causative microorganisms was possible by microbiological and/or histopathological analysis of tissue samples, of which polymerasechain reaction testing (PCR) of the 16S ribosomal RNA proved to be most successful. The present study provides a detailed analysis of blood culture-negative endocarditis over a time span of more than 20 years in Zurich, Switzerland. Antibiotic treatment prior to blood collection, and fastidious and slow growing organisms were identified as main reasons for sterile blood cultures. Typical culture-negative bacteria were mainly found by PCR and/or culture of tissue samples.

Value of diagnosing immunological phenomena in patients with suspected endocarditis

PurposeImmunological phenomena are a minor criteria in the modified Duke Criteria for endocarditis. Given the changes in epidemiology and diagnostics, the added value of determining these phenomena in today’s patients with suspected endocarditis is unknown.MethodsIn a retrospective cohort study of all patients with suspected endocarditis admitted to our hospital and discussed in our endocarditis team, we determined the proportion of patients classified as definite endocarditis because of either positive IgM rheumatoid factor (IgM RF), haematuria, or Roth’s spots on ophthalmology consultation. We also determined diagnostic accuracy of each of these immunological phenomena separately and combined.ResultsOf 285 patients included, 138 (48%) had definite endocarditis and at least one immunological test was performed in 222 patients (78%). Elevated IgM RF was found in 22 of 126 patients tested (17%), haematuria in 78 of 196 tested (40%) and Roth’s spots in six of 120 tested (5%). Eighteen of 138 patients with definite IE (13%) were classified as such because of a positive IgM RF, haematuria or Roth’s spots. Haematuria had the highest sensitivity: 50.5% (95% CI 40.4–60.6) and Roth’s spots the highest specificity: 98.3% (95% CI 90.8–99.9). The diagnostic accuracy results were robust in a sensitivity analysis aimed at avoiding incorporation bias.ConclusionAmong patients with a clinical suspicion of endocarditis, recommended systematic testing for immunological phenomena helped classify more patients as definite IE and is useful to confirm the diagnosis of endocarditis.

Prosthetic Joint Infection Due to Cardiobacterium hominis: Report of First Known Case and Review of C. hominis Septic Arthritis Literature

Introduction. The Cardiobacterium species is a pleomorphic Gram-negative bacterium discovered in 1964 and is part of the HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, and Kingella) group of organisms known to cause endocarditis. It has low virulence and can also cause dacryocystitis, septicemia and abdominal abscess. We report a patient with C. hominis prosthetic joint infection in the absence of definitive endocarditis. Case Report. A 57-year-old man presented to his orthopedic surgeon 17 months after left total knee arthroplasty with a 4–5-day history of left knee pain following yard work. He had an aortic valve replacement in 2003, mitral valve repair in 2006 and bovine aortic valve replacement in 2019 (12 months previously). Aspirate of knee joint fluid was grossly cloudy. Two of two preoperative blood cultures revealed Cardiobacterium species after 4 days’ incubation. He was initially treated with intravenous vancomycin plus piperacillin/tazobactam followed by 6 weeks of parenteral ceftriaxone followed by five months of oral cefdinir. Patient is infection-free 6 months after completion of antimicrobial therapy. Discussion. Cardiobacterium hominis is a slow-growing, fastidious, capnophilic, Gram-negative bacillus commonly found in normal oral and upper respiratory flora. Google Scholar™ and PubMed®searches were conducted and this is the first reported case of prosthetic joint infection due to Cardiobacterium hominis. We found three previously reported cases of C. hominis pyogenic arthritis: one patient with native knee pyogenic arthritis, one patient with cervical spondylodiscitis and one patient with lumbar spondylodiscitis and epidural abscess. Two of these three patients had TEE-documented infective endocarditis and one had a bioprosthetic aortic valve without evident vegetation on TEE. Our patient had a bioprosthetic aortic valve without TEE evidence of endocarditis. C. hominis should be added to the list of organisms that can cause bacteremically spread prosthetic joint infection.

The prevalence of persistent bacteraemia in patients with a non-staphylococcal infective endocarditis, a retrospective cohort study

BackgroundCurrent guidelines on the management of infective endocarditis (IE) recommend follow-up blood cultures (FUBCs) to identify persistent bacteraemia, as this has prognostic value and guides treatment decisions. While persistent bacteraemia frequently occurs in Staphylococcus aureus bacteraemia and IE, its prevalence and impact in non-staphylococcal IE is largely unknown. We determined prevalence and prognostic value of persistent bacteraemia in non-staphylococcal IE. MethodsWe conducted a retrospective analysis of all patients diagnosed with definite non-staphylococcal endocarditis according to the modified Duke Criteria in two university hospital endocarditis registries We determined the prevalence and prognostic value of persistent bacteraemia. ResultsOf the included 159 patients 70 (44%) had prosthetic valve endocarditis (PVE). A median number of two [IQR 1–3] FUBCs were taken during the first week, with 134/159 (84%) having at least one FUBC in the first four days. Seven patients (4,4%) had persistent bacteraemia 48 h after start of antibiotic treatment: 5/70 patients (7.1%) with PVE and 2/89 (2.2%) with native valve endocarditis. Among 97 patients with streptococcal IE, nine patients with HACEK IE and six patients with Cutibacterium IE, no persistent bacteraemia was observed. Enterococcus faecalis was the causative microorganism in five patients with persistent bacteraemia, the other two had non-HACEK Gram-negative endocarditis. ConclusionPersistent bacteraemia in non-staphylococcal endocarditis was rare. It was more frequently observed in PVE and was restricted to more resilient microorganisms such as enterococci and non-HACEK Gram-negative bacteria. Routine collection of FUBCs in patients with streptococcal endocarditis has a low yield and may require re-evaluation.

Vertebral Osteomyelitis and Infective Endocarditis Co-Infection.

Many cases of vertebral osteomyelitis (VO) and infective endocarditis (IE) co-infection have been reported, and it has been recognized that attention should be paid to the possibility of both diseases co-existing during diagnosis and treatment. However, the incidence, clinical status, and outcomes of IE in patients with VO remain unclear. For this study, the eligibility criteria for patient recruitment included all cases of VO at the five medical university hospitals. Patients with a history of spinal surgery were excluded from this study. Echocardiography was routinely performed for all patients with VO. IE was diagnosed according to the modified Duke criteria for definite endocarditis. We analyzed demographic data, underlying conditions, clinical features, laboratory data, echocardiography, radiologic images, treatments, and outcomes. VO was diagnosed in 59 patients and IE was diagnosed in seven patients (12%). There were no significant differences in the clinical features, microorganisms, or radiographic status between the VO-IE co-infection and VO-only groups. In this study, using routine echocardiography for VO, the IE prevalence was 12%. The lack of specific clinical features and laboratory findings may hamper the diagnosis of IE. Therefore, clinicians are always required to suspect IE in patients with VO.

Risk stratification score screening for infective endocarditis in patients with Gram-positive bacteraemia

Background A feared cause of bacteraemia with Gram-positives is infective endocarditis. Risk stratification scores can aid clinicians in determining the risk of endocarditis. Six proposed scores for the use in bacteraemia; Staphylococcus aureus (PREDICT, VIRSTA, POSITIVE), non-β-haemolytic streptococci (HANDOC) and Enterococcus faecalis (NOVA, DENOVA) were validated for predictive ability and the utilization of echocardiography was investigated. Methods Hospitalized adult patients with Gram-positive bacteraemia during 2017–2019 were evaluated retrospectively through medical records and the Swedish Death Registry. Baseline and score-specific data, definite endocarditis and echocardiographies performed were recorded. Sensitivity, specificity, negative and positive predictive values and echocardiography utilization were determined. Results 480 patients with bacteraemia were included and definite endocarditis was diagnosed in 20 (7.5%), 10 (6.6%), and 2 (3.2%) patients with S. aureus, non-β-haemolytic streptococci and E. faecalis, respectively. The sensitivities of the scores were 80–100% and specificities 8–77%. Negative predictive values of the six scores were 98–100%. VIRSTA, HANDOC, NOVA and DENOVA identified all, the PREDICT5 score missed 1/20 and the POSITIVE score missed 4/20 cases of endocarditis. Transoesophageal echocardiography was performed in 141 patients (29%). Thus, the risk stratification scores suggested an increase of 3–63 (7–77%) investigations with echocardiography. Conclusions All scores had negative-predictive values over 98%, therefore it can be concluded that PREDICT5, VIRSTA, POSITIVE, HANDOC and DENOVA are reasonable screening tools for endocarditis early on in Gram-positive bacteraemia. The use of risk stratification scores will lead to more echocardiographies.

Sign of the Times: Updating Infective Endocarditis Diagnostic Criteria to Recognize Enterococcus faecalis as a Typical Endocarditis Bacterium.

The modified Duke criteria requires that Enterococcus faecalis bacteremia must be both community-acquired and without known focus in order to be considered a microbiological "Major" diagnostic criterion in the diagnosis of infective endocarditis. We believe that the microbiological diagnostic criteria should be updated to regard E. faecalis as a "typical" endocarditis bacterium as is currently the case, for example, viridans group streptococci and Staphylococcus aureus. Using data from a prospective study of 344 patients with E. faecalis bacteremia evaluated with echocardiography, we demonstrate that designating E. faecalis as a "typical" endocarditis pathogen, regardless the place of acquisition or the portal of entry, improved the sensitivity to correctly identify definite endocarditis from 70% (modified Duke criteria) to 96% (enterococcal adjusted Duke criteria).

Multimodality imaging leads to increased diagnostic certainty for the endocarditis multidisciplinary team

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): NA Background Endocarditis is a complex condition with high rates of morbidity and mortality. The clinical presentation is highly variable and diagnosis may be difficult. ESC guidelines include modified diagnostic criteria utilising both Duke criteria and multimodality imaging techniques in order to improve sensitivity. A Multidisciplinary Endocarditis Team (MDT) is recommended to improve patient care and has been shown to reduce 1 year mortality. We have established a local endocarditis team, with remote input from our regional cardiothoracic centre. During weekly virtual multidisciplinary meetings (MDM), all patients with suspected endocarditis are discussed, with recommendations on investigations, antimicrobial therapy and management. Purpose We audited the use of multimodality imaging in the diagnosis of endocarditis before and after the implementation of the MDM to compare management strategies. Methods Inpatients who were clinically diagnosed and treated for endocarditis in the first 6 months of 2019 (pre MDT – Group 1, n = 30) and 2021 (with MDT input - Group 2, n = 21) were included. Likelihood of endocarditis was calculated using the modified Duke score and multimodality imaging, resulting in categories of definite IE, possible IE and rejected IE. Imaging specifically requested for the diagnosis of endocarditis (or infection/embolic source) was recorded. Where imaging criteria were demonstrated, the modality making this diagnosis was recorded. Results In both groups all patients had a transthoracic echocardiogram (TTE) with a similar diagnostic yield: (20%) in group 1 and 6(29%) in group 2, p = 0.481. In group 1, 13 patients without diagnostic criteria on TTE had a second investigation, with a further 4 meeting imaging criteria. 1 patient had a third test. In group 2, 13 had a second test with a further 8 meeting imaging criteria. 3 patients had a third test with 1 further positive result (Figure 1). There was increased usage of additional testing after a normal TTE in group 2 (87%) compared to group 1 (54%), p = 0.036. Overall, in group 1, 10(33%) patients demonstrated imaging criteria for endocarditis. In group 2, this increased to 15(71%), p = 0.008. A wider spread of imaging techniques was used in group 2 (Figure 1). In group 1, diagnostic criteria were found on TTE (60%) or TOE (40%). In group 2, they were seen from all four modalities: TTE (40%), TOE (33%), FDG-PET (20%) and CT (7%). In group 1, the spread of diagnostic classification was: • Definite endocarditis - 6(20%) • Possible endocarditis - 13(43%) • Rejected endocarditis - 11(37%) In group 2, this was: • Definite endocarditis - 12(57%) • Possible endocarditis - 9(43%) Conclusion Creation of endocarditis MDT resulted in increased use of multimodality imaging in patients with suspected endocarditis, resulting in a higher diagnostic yield and an increase in diagnostic certainty. Abstract Figure.

Abstract WP177: Trends In The Clinical Phenotype Of Infective Endocarditis Related Stroke From 2005-2015: A Population-Based Study Of The Greater Cincinnati/ Northern Kentucky Region

Background: Prior studies have demonstrated a rising incidence of infective endocarditis related stroke (IERS) in the US due to the opioid epidemic. The Greater Cincinnati/Northern Kentucky (GCNK) region has one of the highest opioid abuse rates in the nation. A modern epidemiologic description is necessary to understand the impact of the opioid epidemic on the clinical phenotype of IERS. Methods: Using the GCNK Stroke Study, all patients hospitalized with IERS in 2005, 2010, and 2015 were abstracted and physician reviewed. IERS was defined as an acute stroke clinically attributed to infective endocarditis in patients meeting modified Duke Criteria for possible or definite endocarditis. Comparison between years were by chi-square or Fisher’s exact test for categorical variables; ANOVA or Kruskal-Wallis test for numerical variables. Cochran-Armitage test was used to examine trend. Secondary analysis compared characteristics between intravenous drug users (IVDU) and non-IVDU. Results: A total of 54 patients with IERS were identified in 2005, 2010, and 2015. Over the period, there was a significant decline in hypertension (91.7% in 2005, 36.0% in 2015; p=0.0005) and increase in IVDU (8.3% in 2005, 44.0% in 2015; p=0.02). They trended towards increased white race, younger age, and fewer vascular risk factors. Compared to non-IVDU, IVDU were significantly younger (41.1±14.1vs 63.1±14.3 years; p&lt;0.001), less often female (12.5% vs 47.4%; p=0.02), had higher rates of sepsis (50% vs 18.4%; p=0.04), less atrial fibrillation (0% vs 31.6%; p=0.01), and less renal disease (0% vs 23.7%; p=0.045). The incidence of IERS per 100,000 increased from 1.31 (CI: 0.56-2.06) in 2005, to 1.66 (CI: 0.87-2.45) in 2010, and to 2.41(CI:1.46-3.36) in 2015. Conclusion: From 2005 to 2015, IERS was increasingly associated with IVDU and an absence of hypertension. These trends likely reflect the demographics of the opioid epidemic, which has affected younger patients with less comorbidities.