Definite Endocarditis Research Articles

Enterococcal endocarditis in Sweden, 1995-1999: can shorter therapy with aminoglycosides be used?

A 5-year nationwide prospective study in Sweden during 1995-1999 identified 881 definite episodes of infective endocarditis. Definite enterococcal endocarditis was diagnosed in 93 episodes (11%), the largest series of enterococcal endocarditis so far presented. Mortality during treatment was 16%, the relapse rate was 3%, and clinical cure was achieved in the remaining 81% of the episodes. Clinical cure was achieved with a median duration of cell wall-active antimicrobial therapy of 42 days combined with an aminoglycoside (median treatment time, 15 days). International guidelines generally recommend a 4-6-week combined synergistic treatment course with a cell wall-active antibiotic and an aminoglycoside. Treatment regimens in Sweden often include a shortened aminoglycoside treatment course in order to minimize adverse effects in older patients. Fatal outcome seemed not to be due to the shortened aminoglycoside therapy course. In many enterococcal endocarditis episodes, duration of aminoglycoside therapy could probably be shortened to 2-3 weeks.

Comparison of clinical and echocardiographic characteristics of Streptococcus bovis endocarditis with that caused by other pathogens

The aim of our study was to compare the clinical, echographic, and prognostic features of Streptococcus bovis ( S. bovis) endocarditis with those caused by other streptococci and pathogens in a large sample of patients with definite endocarditis by Duke criteria, using transesophageal echocardiography. Two hundred six patients (149 men, mean age 57 ± 15 years) with a diagnosis of infective endocarditis formed the study population. All patients underwent multiplane transesophageal echocardiography and blood cultures. Cerebral, thoracoabdominal computed tomographic scan was performed in almost all patients (95%). All patients with S. bovis endocarditis underwent colonoscopy. Incidence of S. bovis endocarditis in our sample was 19%. Patients with S. bovis endocarditis were older than other groups. Multiple valve involvement, native valves, and large vegetations (>10 mm) were more frequent in patients with S. bovis. There was a significantly higher occurrence of embolism in the S. bovis group. Splenic embolism and multiple embolisms were significantly more frequent in patients with S. bovis. Gastrointestinal lesions, anemia, and spondylitis were observed more frequently with S. bovis endocarditis. In addition to the requirement for gastrointestinal examination for S. bovis endocarditis, our study underlines the need for systematic screening for vertebral and splenic localizations, and suggests the use of early surgery to prevent the high risk of embolism in these patients.

Endocardites à Coxiella burnetii sur prothèse : six observations

Purpose. – Prosthetic valve endocarditis is a dangerous complication of valvular surgery (3–6%). Among involved pathogens, Coxiella burnetii is an occasional agent, though isolated with increasing frequency. We report our experience with this peculiar endocarditis and lay stress on specific diagnostic and therapeutic difficulties. Methods. – Between 1990 and 1995, six patients retrospectively met the diagnosis criteria for definite endocarditis due to Coxiella burnetii. Results. – Five Algerian men and one French woman presented with prosthetic valve endocarditis with negative blood cultures (on bioprosthesis: four cases, on mechanical valve: two cases). The main clinical and biological feature was febrile congestive heart failure with hepatomegaly, splenomegaly, hepatic and renal abnormalities, inflammatory syndrome, hypergammaglobulinemia, anemia and lymphopenia. Serological testing for Coxiella burnetii provided diagnosis in all cases. Echocardiography displayed vegetations in all cases. Valvular replacement was performed in four patients. With antibiotic therapy including doxycycline or/and hydroxychloroquine, quinolones or rifampicine, all patients experienced complete clinical, biological and echographic remission. Conclusion. – Q fever prosthetic valve endocarditis presents as a systemic disorder occurring in patients with valvular heart disease. From now on, early diagnosis and efficient medical treatment may provide permanent prosthetic sterilization.

Epidemiologic and clinical characteristics of Bartonella quintana and Bartonella henselae endocarditis: a study of 48 patients.

Epidemiologic and clinical characteristics of Bartonella quintana and Bartonella henselae endocarditis: a study of 48 patients.

A retrospective review of 228 episodes of infective endocarditis where rheumatic valvular disease is still common

Two hundred and twenty-eight episodes of infective endocarditis in adult patients (mean age 36 years) were reviewed retrospectively. There were 183 episodes (80%) of native valve, 15 (7%) early prosthetic valve and 30 (13%) late prosthetic valve endocarditis. The most common predisposing factor was rheumatic valvular disease (65%). None of the patients were intravenous drug users. According to the Duke criteria, the number of definite, probable and rejected episodes were 121 (53%), 94 (41%) and 13 (6%), respectively. Additional minor criteria increased the number of definite endocarditis to 82%. The Duke criteria are not primarily intended to influence treatment decisions but are helpful in standardising research activities. The choice of the level of sensitivity or specificity of the criteria may be adjusted according to the aim of the study and prevalence of disease in a particular area. More sensitive criteria may be valuable in those countries where the prevalence of rheumatic valvular disease is still high.

Echocardiography predicts embolic events in infective endocarditis

OBJECTIVESThe aim of our study was to assess the value of transesophageal echocardiography (TEE) in predicting embolic events (EEs) in a large group of patients with definite endocarditis according to the Duke criteria, including silent embolism.BACKGROUNDThe value of echocardiography in predicting embolism in patients with endocarditis remains controversial. Some studies reported an increased risk of embolism in patients with large and mobile vegetations, whereas other studies failed to demonstrate such a relationship.METHODSMultiplane transesophageal echocardiograms of 178 consecutive patients with definite infective endocarditis (IE) were analyzed. The incidence of embolism was compared with the echocardiographic characteristics (localization, size and mobility) of the vegetations. To detect silent embolism, cerebral and thoraco-abdominal scans were performed in 95% of patients.RESULTSAmong 178 patients, 66 (37%) had one or more EEs. There was no difference between patients with and without embolism in terms of age, gender and left valve involved. On univariate analysis, Staphylococcusinfection, right-side valve endocarditis and vegetation length and mobility were significantly related to EEs. A significant higher incidence of embolism was present in patients with vegetation length >10 mm (60%, p < 0.001) and in patients with mobile vegetations (62%, p < 0.001). Embolism was particularly frequent among 30 patients with both severely mobile and large vegetations (>15 mm) (83%, p < 0.001). On multivariate analysis, the only predictors of embolism were vegetation length (p = 0.03) and mobility (p = 0.01).CONCLUSIONSOur study shows that the presence of vegetations on TEE is predictive of embolism and that the morphologic characteristics of vegetations are helpful in predicting EEs in both mitral and aortic valve IE. It also suggests that early operation may be recommended in patients with vegetations >15 mm and high mobility, irrespective of the degree of valve destruction, heart failure and response to antibiotic therapy.

Staphylococcus aureus bacteremia in the surgical patient: a prospective analysis of 73 postoperative patients who developed Staphylococcus aureus bacteremia at a tertiary care facility

Background: Staphylococcus aureus is a frequent cause of infection and bacteremia in the postoperative patient. Unfortunately, there have been no prospective studies evaluating these patients, so the incidence of complications, subsequent treatment algorithms, and prognosis remain undefined. The objectives of this prospective study of postoperative Staphylococcus aureus bacteremia (SAB) were to define the primary sources of bacteremia and to identify the common complications of SAB in the postoperative setting.Methods: A registry was developed into which 309 consecutive adult patients with SAB were prospectively enrolled between September 1994 and December 1996. Seventy-three of these patients (23.6%) developed SAB in the postoperative setting.Results: Analysis of the clinical features of these 73 postoperative patients revealed three important results. First, infective endocarditis is surprisingly common in postoperative patients with SAB and the classical stigmata of endocarditis are often absent. Transesophageal echocardiography was performed in 31 of 73 patients; 10 of these patients (32.3%) met Duke Criteria for definite endocarditis, but only 3 of these patients had vegetations detected by transthoracic echocardiography, and only 2 patients had peripheral stigmata of infective endocarditis. mSecond, the development of SAB after cardiothoracic surgery was strongly associated with underlying S. aureus mediastinitis. Twenty-one of the 23 patients who developed SAB after median sternotomy had mediastinitis (positive predictive value 91.3%). In many cases, the diagnosis of mediastinitis was not apparent when SAB was detected. Third, complications, relapses, and mortality were high in postoperative patients with SAB. Fourteen of 73 patients (19.2%) developed multiple noncardiac metastatic complications, including metastatic abscesses (5), septic emboli (3), pneumonia or empyema (2), septic arthritis (1), epidural abscess (1), and other metastatic foci (7). Twelve of 73 patients (16.4%) had recurrent staphylococcal infection after treatment of their first episode of SAB, including 8 patients (11.0%) with recurrent bacteremia. Of patients who survived, those with recurrent staphylococcal infection were more likely to have an infected surgical wound than were patients who were cured of infection (p = 0.05). Finally, mortality attributable to SAB (11.0%), and all-cause mortality (21.9%), was high.Conclusions: SAB in the postoperative setting is often a severe disease with high morbidity and mortality. A thorough diagnostic evaluation is indicated in surgical patients with S. aureus bacteremia to ensure the early detection of metastatic infections such as infective endocarditis and to define foci such as mediastinitis requiring surgical intervention.

Long term follow up of prosthetic valve endocarditis: what characteristics identify patients who were treated successfully with antibiotics alone?

OBJECTIVETo identify predictors for the safe use of antibiotic treatment without reoperation in patients with prosthetic valve endocarditis.SETTINGRetrospective study in a tertiary care centre.SUBJECTS AND DESIGNAll 49 episodes of definite...

Pacemaker infective endocarditis

We identified 33 patients with definite pacemaker endocarditis—that is, with direct evidence of infective endocarditis, based on surgery or autopsy histologic findings of or bacteriologic findings (Gram stain or culture) of valvular vegetation or electrode-tip wire vegetation. Most of the patients (75%) were ≥60 years of age (mean 66 ± 3; range 21 to 86). Pouch hematoma or inflammation was common (58%), but other predisposing factors for endocarditis were rare. At the time that pacemaker endocarditis was found, the mean number of leads was 2.4 ± 1.1 (range 1 to 7). The interval from the last procedure to diagnosis of endocarditis was 20 ± 4 months (range 1 to 72). Endocarditis appeared after pacemaker implantation, early (<3 months) in 10 patients and late (≥3 months) in 23 patients. Fever was the most common symptom, being isolated in 36%, associated with a poor general condition in 24%, and associated with septic shock in 9%. Transthoracic echocardiography showed vegetations in only 2 of 9 patients. Transesophageal echocardiography demonstrated the presence of lead vegetations (n = 20) or tricuspid vegetations (n = 3) in 23 of 24 patients (96%; p <0.0001 compared with transthoracic echocardiography). Pulmonary scintigraphy showed a typical pulmonary embolization in 7 of 17 patients (41%). Pathogens were mainly isolated from blood (82%) and lead (91%) cultures. The major pathogens causing pacemaker endocarditis were Staphylococcus epidermidis (n = 17) and S. aureus (n = 7). S. epidermidis was found more often in early than in late endocarditis (90% vs 50%; p = 0.05). All patients were treated with prolonged antibiotic regimens before and after electrode removal. Electrode removal was achieved by surgery (n = 29) or traction (n = 4). Associated procedures were performed in 9 patients. After the intensive care period, only 17 patients needed a new permanent pacemaker. Overall mortality was 24% after a mean follow-up period of 22 ± 4 months (range 1 to 88). Eight patients who were significantly older (74 ± 3 vs 63 ± 3 years; p = 0.05) died ≤2 months after electrode removal, whereas 25 were alive and asymptomatic.

Pneumococcal endocarditis is not just a disease of the past: an analysis of 16 cases diagnosed in Denmark 1986-1997.

To remind clinicians and clinical microbiologists of the clinical features and therapeutic aspects of pneumococcal endocarditis, patients with pneumococcal endocarditis from 1986 to 1997 were identified via an enquiry to clinical microbiologists across Denmark. For all patients records were reviewed to confirm the diagnosis of pneumococcal endocarditis, and the clinical course, therapy and outcome were analysed. 16 patients with definitive pneumococcal endocarditis were found. All pneumococcal isolates were sensitive to penicillin. 15 patients had no previously known cardiac valvular disease, 10 patients had X-ray-proven pneumonia and 5 had meningitis. The aortic valve was affected in 13 patients, of whom 12 developed aortic insufficiency and 11 cardiac failure. Of 7 patients who underwent surgery, 6 needed immediate cardiac valve replacement. The 30-day case fatality rate was 19% (95% confidence limits 4-46%). Pneumococcal endocarditis must be considered when treating patients with pneumococcaemia. The most important clue to the diagnosis is a significant murmur and development of heart failure. Evaluation by transoesophageal echocardiography is helpful in determining the diagnosis and assessing the need for surgical intervention. With appropriate antibiotic therapy, close observation and cardiac valve replacement if necessary, the prognosis is better than recorded in earlier studies.

An evaluation of the Duke criteria in 25 pathologically confirmed cases of prosthetic valve endocarditis.

Six studies have compared the sensitivity of the Duke criteria with that of the Beth Israel criteria for the diagnosis of infective endocarditis without attempting to distinguish between native valve and prosthetic valve cases. After reviewing clinical data from 372 cases of suspected prosthetic valve endocarditis, we selected 25 cases in which pathological confirmation of prosthetic valve endocarditis was obtained. By using the Duke criteria and then the Beth Israel criteria, we reassigned a diagnostic classification to these 25 cases on the basis of clinical parameters alone. Using the Duke criteria, we correctly classified 19 cases (76%) as definite endocarditis and rejected none, while the Beth Israel criteria correctly classified six cases as probable endocarditis (24%) and rejected five cases (20%). Similar to previous investigators who examined the diagnostic sensitivity of the Duke criteria and Beth Israel criteria, we found that the Duke criteria appear more sensitive than the Beth Israel criteria in pathologically confirmed cases of prosthetic valve endocarditis.

Diagnosis of 22 new cases of Bartonella endocarditis.

Bartonella species are emerging pathogens that are seldom reported as a cause of blood culture-negative endocarditis. To report the occurrence of, risk factors for, and clinical features of Bartonella endocarditis and to evaluate the diagnostic tools available for this condition. Case series and comparison with past series. Multicenter international study in Halifax, Nova Scotia, Canada; Lyon, France; and Marseille, France. 22 patients from France, England, Canada, and South Africa were investigated for blood culture-negative endocarditis. Titer of antibodies to Bartonella species by microimmunofluorescence assay, blood or vegetation culture, and amplification of Bartonella DNA from valvular tissue by polymerase chain reaction. Cross-adsorption was done for patients with antibodies to Chlamydia species. 22 patients had definite endocarditis. Five were infected with B. quintana, 4 with B. henselae, and 13 with an undetermined Bartonella species. These cases were compared with the 11 previously reported cases. Of the patients with the newly reported cases, 19 had valvular surgery and 6 died. Nine were homeless, 11 were alcoholic, 4 owned cats, and 13 had preexisting valvular heart disease. Bartonella species caused 3% of the cases of endocarditis seen in the three study centers. The patients with these cases could have previously received a diagnosis of chlamydial endocarditis because of apparently high levels of cross-reacting antibodies to Chlamydia species. Bartonella species are an important cause of blood culture-negative endocarditis and can be identified by culture, serologic studies, or molecular biology techniques. Alcoholism and homelessness without previous valvular heart disease are risk factors for B. quintana infection but not for infection with other Bartonella species.

Epidemiologic aspects of infective endocarditis in an urban population. A 5-year prospective study.

A prospective study of the epidemiology of infective endocarditis (IE) in a well-defined urban population of 428,000 inhabitants during a 5-year period was carried out. All patients were treated in the same institution, and history, diagnostic procedures, and treatment were standardized. Of 233 consecutive suspected episodes of IE, 127 fulfilled the modified von Reyn criteria. After patients not living in the defined area were excluded, 99 episodes in 90 patients were analyzed in the epidemiologic part of the study. Of these, 33 episodes were definite endocarditis, verified by surgery or autopsy; 35 probable; and 31 possible endocarditis episodes. Another 34 episodes were found retrospectively and are included in the incidence calculation. The crude incidence was calculated to be 6.2/100,000 inhabitants per year, which is high compared to earlier studies. Adjusted to the population of Sweden, the incidence was 5.9/100,000 inhabitants per year. The annual incidence was higher for women, 6.6/100,000, than for men, 5.8/100,000. In the oldest age-group (80-89 years) the annual incidence was 22/100,000 in the prospective study and 30/100,000 if retrospective cases were included. Contrary to almost all other studies, we did not find a male predominance among our cases. Only 7% of patients were intravenous drug abusers, and 15% had a prosthetic valve. The most common bacteria were methicillin-susceptible Staphylococcus aureus (31%) and alpha-streptococci (28%); 12% of episodes were culture negative. The mortality from IE in the population was 1.4/100,000 inhabitants per year. A higher-than-expected incidence of IE was found, especially among older patients and women.

Endocarditis-Associated Paravalvular Abscesses: Do Clinical Parameters Predict the Presence of Abscess?

To determine whether standard clinical and transthoracic echocardiographic criteria considered to be suggestive of the presence of endocarditis-associated paravalvular abscess are predictive of which patients would benefit from reliable but invasive transesophageal echocardiographic investigations for abscess. Retrospective chart review. A 630-bed university hospital. Forty-eight patients with 51 episodes of definite endocarditis and 24 paravalvular abscesses. A comparison of abscess and nonabscess populations revealed that clinical parameters (patient demographics, valvular involvement, presence of a prosthesis, infection with a virulent organism, pericarditis, persistent fever, persistent bacteremia, congestive heart failure, history of intravenous drug use, embolization) and transthoracic echocardiographic parameters were insensitive predictors of the presence of abscess. The only statistically significant correlate was the presence of previously undetected atrioventricular or bundle branch block. Paravalvular abscesses were common in our population and were associated with increased mortality. Improved survival correlated with the absence of mitral valve involvement and the absence of moderate-to-severe congestive heart failure. Given the accuracy and safety of transesophageal echocardiography and the unreliability of clinical and transthoracic echocardiographic criteria, we recommend that transesophageal echocardiography be considered in all endocarditis patients with previously unrecognized conduction disturbances, aortic or prosthetic valve involvement, or both, or indications for valve replacement, or all of the foregoing.

New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings

purpose: This study was designed to develop improved criteria for the diagnosis of infective endocarditis and to compare these criteria with currently accepted criteria in a large series of cases. patients and methods: A total of 405 consecutive cases of suspected infective endocarditis in 353 patients evaluated in a tertiary care hospital from 1985 to 1992 were analyzed using new diagnostic criteria for endocarditis. We defined two “major criteria” (typical blood culture and positive echocardiogram) and six “minor criteria” (predisposition, fever, vascular phenomena, immunologic phenomena, suggestive echocardiogram, and suggestive microbiologic findings). We also defined three diagnostic categories: (1) “definite” by pathologic or clinical criteria, (2) “possible,” and (3) “rejected.” Each suspected case of endocarditis was classified using both old and new criteria. Sixty-nine pathologically proven cases were reclassified after exclusion of the surgical or autopsy findings, enabling comparison of clinical diagnostic criteria in proven cases. results: Fifty-five (80%) of the 69 pathologically confirmed cases were classified as clinically definite endocarditis. The older criteria classified only 35 (51%) of the 69 pathologically confirmed cases into the analogous probable category (p <0.0001). Twelve (17%) pathologically confirmed cases were rejected by older clinical criteria, but none were rejected by the new criteria. Seventy-one (21%) of the remaining 336 cases that were not proven pathologically were probable by older criteria, whereas the new criteria almost doubled the number of definite cases, to 135 (40%, p <0.01). Of the 150 cases rejected by older criteria, 11 were definite, 87 were possible, and 52 were rejected by the new criteria. conclusion: Application of the proposed new criteria increases the number of definite diagnoses. This should be useful for more accurate diagnosis and classification of patients with suspected endocarditis and provide better entry criteria for epidemiologic studies and clinical trials.

Nonenterococcal Group D Streptococcal Septicemia: Association with Unrecognized Endocarditis

68 patients presented to the Veterans General Hospital, Taipei with nonenterococcal group D streptococcal septicemia in the years 1985-1987. 36 patients (53%) had nonenterococci as part of a polymicrobial bacteremia. The large intestine was not examined in most patients. Five patients (7%) had associated colonic carcinoma, and 17 patients (25%) had colorectal diseases. Only 7/68 patients (10%) were clinically diagnosed as having infective endocarditis by the doctors in charge. The others were regarded as having septicemia. The charts of these patients were reviewed retrospectively to diagnose infective endocarditis based on strict definitions. One (1%) had definite endocarditis proved at autopsy. 16 patients (24%) had probable endocarditis due to the presence of either a new regurgitant murmur or both a predisposing heart disease and embolic phenomena; 39 (57%) had possible endocarditis based on evidence of having either a predisposing heart disease or embolic phenomena; and only 12 (18%) had no evidence of endocarditis. 27 patients (40%) had at least one predisposing heart disease associated with endocarditis. 51 patients (75%) had at least one lesion suggesting embolic phenomena. 30 patients (44%) had electrocardiographic abnormalities. This high incidence of arrhythmia in nonenterococcal septicemia is of particular interest and could be related to cardiac involvement in some patients. The overall mortality, 62% (42/68), was extremely high in our series, but in those who were clinically diagnosed and treated as infective endocarditis, the mortality was low, 14% (1/7). We suggest all patients with nonenterococcal septicemia associated with either heart disease or lesions of CNS, lung, heart, kidney or limbs suggesting embolic phenomena should be regarded as having possible or probable endocarditis. Treating such patients as having infective endocarditis may reduce the mortality in nonenterococcal septicemia.

Infective endocarditis: an analysis based on strict case definitions.

Strict case definitions were applied to 123 clinically diagnosed cases of infective endocarditis. Cases were categorized as definite (19), probable (44), or possible (41) endocarditis or were rejected (19). Compared to other published studies, our patients had an advanced mean age (57), high incidence of underlying valvular disease (66%), short mean duration of symptoms (27 days), and 15% mortality, the lowest reported for a large series. Most cases were caused by viridans streptococci, Staphylococcus aureus, or enterococci; Enterobacteriacae were absent, and negative cultures infrequent (5%). Subgroups included nosocomial endocarditis (13%), usually with underlying valvular disease and invasive procedures; prosthesis endocarditis (12%); and cases requiring cardiac surgery (18%). Deaths were caused by heart failure, neurologic events, or superinfection. Strict definitions are useful in managing suspect cases, and are essential in comparing clinical studies. Early recognition and treatment should be the focus of efforts to reduce mortality from endocarditis.

THE CLINICAL DIAGNOSIS AND SURGICAL MANAGEMENT OF RUPTURED MITRAL CHORDAE TENDINEAE.

Six patients with mitral insufficiency secondary to ruptured chordae tendineae are presented. Each patient underwent surgical correction of the deformed valve. In two instances the posterior leaflet was involved while in four the anterior leaflet was affected. Three patients had definite bacterial endocarditis that appeared to be related to the onset of cardiac symptoms. In the two instances of posterior valve involvement there were an aortic thrill and a harsh systolic murmur, whereas in two of the four with rupture of the anterior leaflet an aortic systolic murmur was heard but no thrill was felt. The other two with anterior leaflet disease disclosed no murmurs in the aortic area. These findings are considered to be a result of the direction of the regurgitant jet and the area in which they strike the left atrium. None of the patients had hemodynamic evidence of aortic valve disease and in each instance the aortic systolic murmur decreased or disappeared after surgery. Each patient had gross left atrial enlargement. Although relatively uncommon, mitral insufficiency due to rupture of the mitral chordae tendineae is readily corrected surgically.

SUBACUTE BACTERIAL ENDOCARDITIS WITH LARGE BRAIN ABSCESS

But few cases of definite subacute bacterial endocarditis associated with brain abscess have been reported. Zolotowa 1 recently described a case with purulent meningo-encephalitis. Kimmelsteil, 2 in an excellent article on the subject, reports several cases with brain abscesses of very minute or microscopic size. Nathan 3 reports a case with microscopic brain abscesses. Winkelman and Eckel 4 cite a case with multiple small brain abscesses. Nadler and Herndon 5 report a case with a pea-sized purulent area in the internal capsule. Gilmore 6 observed a case with two brain abscesses, each about one-half inch in diameter. 7 Dr. Emanuel Libman, who has seen probably more cases of subacute bacterial endocarditis than any one else in America, advises us that he has never observed a case with a brain abscess. 8 Because of the rarity of the occurrence of brain abscess in subacute bacterial endocarditis, and because in most cases