Diagnostic Criteria For Infective Endocarditis Research Articles

Evaluation of the specificity of the 2023 European Society of Cardiology classification for infective endocarditis.

The 2023 Duke-ISCVID and 2023 ESC classifications have recently issued independent diagnostic criteria for infective endocarditis (IE), updating the 2015 ESC criteria. The specificity of the 2023 ESC criteria should be evaluated and compared to the two other classifications in IE suspected patients. We retrospectively collected the characteristics of patients hospitalised in Bichat University Hospital, in 2021, who had been evaluated for suspicion of IE, and in whom IE diagnosis was finally rejected. All were classified by 2015 ESC, 2023 Duke-ISCVID, and 2023 ESC. In total 130 patients were analysed. Mean age was 62 years, 64.6% were male, 30.0% had prosthetic cardiac valve or valve repair, 16.2% had cardiac implanted electronic device, and 23.1% other cardiac conditions. Overall, 2, 5 and 5 patients were falsely classified as definite IE with the 2015 ESC, 2023 Duke-ISCVID and 2023 ESC criteria, respectively. The corresponding specificities were 99% (95% CI [94%; 100%], 96% (95% CI [91%; 99%]), and 96% (95% CI [91%; 99%]). The 2023 ESC and the 2023 Duke-ISCVID criteria are highly specific, although slightly less than the 2015 ESC criteria, for ruling out the diagnosis of definite IE.HIGHLIGHTS2023 Duke-ISCVID and 2023 ESC criteria are recently issued diagnostic classifications2023 ESC criteria have an excellent specificity, equivalent to the 2023 Duke-ISCVID one2023 ESC criteria and the 2023 Duke-ISCVID are less specific than the 2015 ESC criteriaSpecificities were quite similar according to the nature of the cardiac valve (native or prosthetic valve) or the duration of antibiotic therapy.

Infectious endocarditis complicated with intracranial infected aneurysm rupture and sinus of valsalva aneurysm rupture

BackgroundInfectious endocarditis (IE) is an infectious disease caused by direct invasion of the heart valve, endocardium, or adjacent large artery endocardium by pathogenic microorganisms. Despite its relatively low incidence, it has a poor prognosis and a high mortality. Intracranial infectious aneurysms (IIA) and ruptured sinus of Valsalva aneurysm (RSVA) are rare complications of IE.Case presentationWe report a young male patient with symptoms of respiratory tract infection, heart murmurs and other symptoms and signs. The patient also had kidney function impairment and poor response to symptomatic therapy. Blood culture was negative, but echocardiography was positive, which met the diagnostic criteria for infective endocarditis. Moreover, an echocardiography showed a ruptured sinus of Valsalva aneurysm with a ventricular septal defect. Finally, secondary rupture of an IIA with multiple organ damage led to a poor clinical outcome.ConclusionTherefore, in the clinical setting, for young patients with unexplained fever, chest pain, or palpitations, we need to be highly vigilant, considering the possibility of infective endocarditis and promptly performing blood culture, echocardiography, cerebrovascular imaging and so on, in order to facilitate early proper diagnosis and treatment.

Make Modern Microbiology Matter More in the 2023 European Society of Cardiology Guidelines for the Management of Infective Endocarditis.

The European Society of Cardiology (ESC) 2023 guidelines for the management of infective endocarditis (IE) stress that a multidisciplinary approach is needed to manage patients with IE. In our view, the guidelines do not include the relevant perspectives from modern microbiology. The diagnostic criteria for IE were changed in the ESC 2023 guidelines, and many IE-causing pathogens are either not clearly defined. Moreover, an improved understanding of the relationship between bacterial species and the risk for IE has not been implemented. The guidelines give detailed and, in our view, incorrect instructions about diagnostic testing in blood culture-negative IE without presenting proper evidence. Other important diagnostic aspects, such as the value of repeated blood cultures and incubation time for blood cultures, are not discussed. We believe that a multidisciplinary collaboration that include microbiologists would have improved these guidelines, and we hope for a future harmonization of diagnostic criteria for IE.

Lower Specificity of the European Society of Cardiology 2023 Diagnostic Criteria for Infective Endocarditis When Spondylodiscitis Is Regarded as a Vascular Phenomenon.

The ESC diagnostic criteria for infective endocarditis (IE) added spondylodiscitis as a minor criterion. This resulted in that 11 of 1807 patients with Staphylococcus aureus, streptococcal, or Enterococcus faecalis bacteremia, were reclassified from possible to definite IE, of whom only two were treated as IE.

Performance of the 2023 Duke-International Society of Cardiovascular Infectious Diseases Diagnostic Criteria for Infective Endocarditis in Relation to the Modified Duke Criteria and to Clinical Management-Reanalysis of Retrospective Bacteremia Cohorts.

Revised diagnostic criteria for infective endocarditis (IE), the 2023 Duke-ISCVID criteria, were recently presented and need validation. Here, we compare the 2000 modified Duke criteria for IE with Duke-ISCVID among patients with bacteremia and relate the diagnostic classification to IE treatment. We reanalyzed patient cohorts with Staphylococcus aureus, Staphylococcus lugdunensis, non-β-hemolytic streptococci, Streptococcus-like bacteria, Streptococcus dysgalactiae, Enterococcus faecalis, and HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) bacteremia. Episodes were classified as definite, possible, or rejected IE with the modified Duke and Duke-ISCVID criteria. Reclassification included the microbiology criteria, positron emission tomography-computed tomography, and cardiac implanted electronic devices. To calculate sensitivity, patients treated for IE were considered as having IE. In 4050 episodes of bacteremia, the modified Duke criteria assigned 307 episodes (7.6%) as definite IE, 1190 (29%) as possible IE, and 2553 (63%) as rejected IE. Using the Duke-ISCVID criteria, 13 episodes (0.3%) were reclassified from possible to definite IE, and 475 episodes (12%) were reclassified from rejected to possible IE. With the modified Duke criteria, 79 episodes that were treated as IE were classified as possible IE, and 11 of these episodes were reclassified to definite IE with Duke-ISCVID. Applying the decision to treat for IE as a reference standard, the sensitivity of the Duke-ISCVID criteria was 80%. None of the 475 episodes reclassified to possible IE were treated as IE. The Duke-ISCVID criteria reclassified a small proportion of episodes to definite IE at the expense of more episodes of possible IE. Future criteria should minimize the possible IE group while keeping or improving sensitivity.

Epidemiological, Bacteriological, and Evolutive Features of Children Hospitalized for Infective Endocarditis in a Tertiary Tunisian Pediatric Department.

Infective endocarditis is a rare condition in childhood, and there is limited data on this disease in Tunisia. This study aims to analyze the epidemiological profile, bacteriological data, and prognosis of infective endocarditis in children admitted to the pediatric department of a University Hospital in Tunisia. We conducted a comparative cross-sectional study in the pediatric department of Sahloul Teaching Hospital in Sousse, a tertiary referral hospital in Tunisia. The study included all children aged ≤ 18 years with infective endocarditis admitted to the tertiary referral center for pediatrics in Sahloul University Hospital from January 1994 to December 2022. The diagnosis of infective endocarditis was based on modified Duke's criteria. Thirty-six patients met the diagnostic criteria for infective endocarditis, resulting in a proportion of 07 cases per 1000 hospital admissions. The mean age was 6 years (range: 40 days to 16 years). Congenital heart disease was identified as the underlying lesion in 23 cases (63.9 %). Blood cultures were positive in 20 patients (55.6 %), predominantly with Staphylococcus species (55 %). The most frequent complications involved the central nervous system (8 cases; 22.2 %). The mortality rate was 25 %, and factors predicting mortality included heart failure on admission or during the hospital stay, increased leukocyte count, and decreased prothrombin time. Our study reveals a shift in the prevalent underlying lesions, with rheumatic heart diseases no longer being the most common. Staphylococcus spp. emerged as the predominant organism in blood cultures. Notably, mortality predictors included heart failure, an elevated leukocyte count, and a decreased prothrombin time rate.

The 2023 Duke-International Society for Cardiovascular Infectious Diseases Criteria for Infective Endocarditis: Updating the Modified Duke Criteria.

The microbiology, epidemiology, diagnostics, and treatment of infective endocarditis (IE) have changed significantly since the Duke Criteria were published in 1994 and modified in 2000. The International Society for Cardiovascular Infectious Diseases (ISCVID) convened a multidisciplinary Working Group to update the diagnostic criteria for IE. The resulting 2023 Duke-ISCVID IE Criteria propose significant changes, including new microbiology diagnostics (enzyme immunoassay for Bartonella species, polymerase chain reaction, amplicon/metagenomic sequencing, in situ hybridization), imaging (positron emission computed tomography with 18F-fluorodeoxyglucose, cardiac computed tomography), and inclusion of intraoperative inspection as a new Major Clinical Criterion. The list of "typical" microorganisms causing IE was expanded and includes pathogens to be considered as typical only in the presence of intracardiac prostheses. The requirements for timing and separate venipunctures for blood cultures were removed. Last, additional predisposing conditions (transcatheter valve implants, endovascular cardiac implantable electronic devices, prior IE) were clarified. These diagnostic criteria should be updated periodically by making the Duke-ISCVID Criteria available online as a "Living Document."

Updating the diagnostic criteria for infective endocarditis: time for a (valve) replacement.

Journal Article Corrected proof Updating the Diagnostic Criteria for Infective Endocarditis: Time for a (Valve) Replacement Get access Molly L Paras Molly L Paras Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA Correspondence: M. L. Paras, Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit St, Bulfinch Suite 130, Boston, MA 02114, USA (mparas@mgh.harvard.edu). Search for other works by this author on: Oxford Academic PubMed Google Scholar Clinical Infectious Diseases, ciad269, https://doi.org/10.1093/cid/ciad269 Published: 04 May 2023 Article history Received: 12 April 2023 Editorial decision: 20 April 2023 Accepted: 03 May 2023 Published: 04 May 2023 Corrected and typeset: 01 June 2023

CARDIOEMBOLIC STROKE SECONDARY TO CULTURE-NEGATIVE AORTIC VALVE ENDOCARDITIS REVEALED AFTER INITIALLY PRESENTING WITH DIABETIC KETOACIDOSIS

TYPE: Case Report TOPIC: Cardiovascular Disease INTRODUCTION: Native-valve infective endocarditis (IE) has been increasing in incidence over the past several decades. This report describes a patient initially presenting with a relatively “routine” case of diabetic ketoacidosis (DKA), treatment of which unmasked an acute cerebrovascular accident, likely provoked by subacute, culture-negative aortic valve endocarditis. CASE PRESENTATION: A 67-year-old Caucasian male with a past medical history of diabetes mellitus, chronic lacunar infarctions, and hypertension was found unresponsive and in DKA at his home by EMS. Upon transfer to our intensive care unit (ICU) he was intubated and started on a DKA treatment protocol, however the patient remained unresponsive and a brain MRI revealed acute to subacute, bilateral basal ganglia and left cerebellar infarcts. Transthoracic echocardiogram revealed a 0.75 cm by 0.66 cm aortic valve vegetation, and with associated fevers and leukocytosis the patient was started on broad spectrum intravenous antibiotics. Sequential blood cultures grew no microorganisms, and autoimmune workup was negative. The patient was extubated on Day 4 but remains encephalopathic with plans for discharge to subacute rehabilitation. DISCUSSION: Literature review did not find any other cases of an insulin-dependent diabetic developing culture-negative endocarditis in the absence of intravenous drug abuse or other major risk factors. In this case, successful diagnosis hinged on acknowledging the potential for “anchoring bias”, as well as an understanding of the diagnostic criteria for infective endocarditis. CONCLUSIONS: This unusual case presentation reflects the importance of bias awareness and cognitive flexibility in developing a differential diagnosis and guiding treatment. The authors would like to acknowledge Dr. Eleanora Feketeova. DISCLOSURE: Nothing to declare. KEYWORD: Endocarditis

LISTERIA BACTEREMIA PRESENTING WITH CEREBRAL ABSCESS AND ENDOCARDITIS IN AN ELDERLY PATIENT WITH CHRONIC IMMUNE THROMBOCYTOPENIA

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Listeria monocytogenes, an intracellular gram-positive bacillus, is a ubiquitous foodborne pathogen that causes Listeriosis. Its clinical spectrum ranges from mild, self-limiting gastroenteritis in immunocompetent individuals to severe, life-threatening, invasive disease affecting persons at the extremes of age, pregnant women, and individuals with cell-mediated immunodeficiencies. Central nervous system involvement by is common – presenting as meningitis, meningoencephalitis or, less frequently, rhombencephalitis. Listerial brain abscesses are rare. Moreover, only 5-8% of these infections are complicated by infective endocarditis (IE). CASE PRESENTATION: A 70-year-old Caucasian man with chronic immune thrombocytopenia (ITP) presented to the ED with acute onset of altered mental status and right-sided weakness. He was afebrile, with no heart murmurs or peripheral stigmata of IE. Neurologic exam findings included disorientation, expressive aphasia, and right-sided hemiparesis. Laboratory findings were unremarkable except for leukocytosis and hyponatremia. Brain MRI showed an irregular rim-enhancing lesion in the left frontal lobe with surrounding edema and midline shift. The lesion was excised with adjacent necrotic tissue and frozen sections were highly suspicious for a high-grade glial neoplasm. He was started empirically on vancomycin, ceftriaxone and metronidazole. Eventually, the organism was identified as Listeria monocytogenes from two sets of blood cultures; hence, antibiotics were de-escalated to ampicillin and gentamicin. Transesophageal echocardiography (TEE) showed mitral valve vegetation. The patient developed fever on day 4; by day 6, he began to defervesce and showed improvement in mental status. On day 9, he was discharged to the inpatient rehabilitation center to complete a total of 6 weeks on IV ampicillin and IV gentamicin. Pathology of the brain mass was subsequently reported as listerial brain abscess with no evidence of malignancy. DISCUSSION: Chronic treatment with high-dose oral glucocorticoids and pre-existing ITP have been independently implicated as predisposing factors in listerial brain abscess. There is a propensity to misdiagnose listerial brain abscess as an intracranial neoplasm due to similar clinical/imaging findings, especially when fever is absent at presentation. In addition, Listeria monocytogenes is an atypical cause of IE. Our patient had no pre-existing structural or valvular heart disease, but he satisfied two major diagnostic criteria for IE – two separate positive blood cultures of Listeria monocytogenes and a TEE demonstrating mitral valve vegetation. CONCLUSIONS: A high index of suspicion is necessary for early recognition and successful treatment of listerial brain abscess and listerial endocarditis in high-risk patients. REFERENCE #1: Tiri B, Priante G, Saraca LM, Martella LA, Cappanera S, Francisci D. Listeria monocytogenes brain abscess: controversial issues for the treatment—two cases and literature review. Case Rep Infect Dis. 2018;2018(6549496):1-9. REFERENCE #2: Hohmann EL, Portnoy DA. Listeria monocytogenes infections. In: Jameson JL, Kasper DL, Longo DL, Fauci AS, Hauser SL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill Education; 2018:1100-1102. REFERENCE #3: Garcia-Granja PE, Lopez J, Vilacosta I, Olmos C, Sarria C, Roman JAS. Infective endocarditis due to Listeria monocytogenes: a report of 4 patients. Cardiol. 2016;69(7):699–709. DISCLOSURES: No relevant relationships by Nili Gujadhur, source=Web Response no disclosure on file for Vanessa Karimi; No relevant relationships by Olushola Ogunleye, source=Web Response

Vascular Complications of Infective Endocarditis: Diagnosis and Management.

Introduction: The complications of infective endocarditis (IE) are frequent and severe. Our aim was to study the clinical and paraclinical profiles and prognosis of vascular complications, observed in a cardiology unit in Oujda, Morocco. Among 57 patients hospitalized for IE between 2015 and 2020 at the cardiology unit, 19 patients, or 33.3% of patients, had one or more vascular complications. We present here a retrospective analysis.Aim: Prevention, early diagnosis, and treatment of vascular complications are primordial to improving prognosis, following the guidelines of the European Society of Cardiology.Patients and methods: We retrospectively studied 57 patients hospitalized for IE. The diagnostic criteria for IE were modified from the Duke University criteria and we present all vascular complications among this cohort.Results: Nineteen patients presented with one or more vascular complications, 10 men and nine women, with a mean age of 49 years. IE had grafted on a mechanical prosthetic valve in four cases. Overall, we found 25 vascular lesions: six neurological complications, five cases of peripheral vascular involvement, nine splenic infarcts, and five recurrent septic pulmonary embolisms (SPEs). The vascular complications accrued after three to 14 days of antibiotherapy or on extension reports; blood cultures were positive in 17 (89.4%) cases; streptococcus was isolated in nine cases; Staphylococcus aureus in seven cases; and acinetobacter in one case.Conclusion: Vascular complications of IE are severe, the most common in our study being splenic infarct. Prevention and early diagnosis are essential to instituting optimal management.All the patients were followed up with a mean follow-up of three years. Late mortality involved one patient in connection with a hemorrhagic stroke secondary to an accident with vitamin K antagonists after its release in one month. No cases of recurrence of endocarditis were noted in this group.Data were collected from archived medical records and analyzed by Statistical Package for the Social Sciences.

Implementation of the 2015 European Society of Cardiology guidelines for the management of infective endocarditis in the Netherlands.

Because the occurrence of infective endocarditis (IE) continues to be associated with high mortality, a working group was created by the Dutch Society of Cardiology to examine how the most recent European Society of Cardiology (ESC) guidelines for IE management could be implemented most effectively in the Netherlands. In order to investigate current Dutch IE practices, the working group conducted a country-wide survey. Based on the results obtained, it was concluded that most ESC recommendations could be endorsed, albeit with some adjustments. For instance, the suggested pre-operative screening and treatment of nasal carriers of Staphylococcus aureus as formulated in the ESC guideline was found to be dissimilar to current Dutch practice, and was therefore made less restrictive. The recently adapted ESC diagnostic criteria for IE were endorsed, while the practical employment of the relevant diagnostic techniques was simplified in an adapted flowchart. In addition, the presence of a multidisciplinary, so-called ‘endocarditis team’ in tertiary centres was proposed as a quality indicator. An adapted flowchart specifically tailored to Dutch practice for microbiological diagnostic purposes was constructed. Lastly, the working group recommended the Stichting Werkgroep Antibioticabeleid (SWAB; Dutch Working Party on Antibiotic Policy) guidelines for IE treatment instead of the antibiotic regimens proposed by the ESC.

A study of clinical and etiological profile of infective endocarditis and its correlation with echocardiography in patients of rheumatic heart disease

Background: This observational study was to determine the offending microorganisms and clinical profile of infective endocarditis in rheumatic heart disease patients in local population of Jharkhand, the response of disease to medical treatment and to evaluate the prognosis of the cases.Methods: 25 cases of Rheumatic heart disease, fulfilling the diagnostic criteria for infective endocarditis were studied prospectively with baseline investigations, blood culture and echocardiography and were treated with appropriate antibiotics.Results: In this study, the mean age observed was 26 year and male patient to female patient ratio was 3.16:1. Aortic valve was the commonest valve to be involved. Cardiac murmurs were present in all patients, splenomegaly was present in 56% of patients but peripheral signs of infective endocarditis were rare. Blood culture was positive in 28% of cases and staphylococcus aureus was the main organism isolated. 23 cases out of 25 cases studied showed vegetations on echocardiography mostly on aortic or mitral valve. In majority of patients (80%) injection Penicillin G and Gentamicin were started in standard recommended dose first on empirical basis but later on suitable antibiotics were started according to sensitivity pattern. Mortality was significantly high (20%).Conclusions: Fever and constitutional symptoms were the most common presentation. Mild to moderate anemia, leucocytosis, high ESR were very common but, peripheral signs were rarely observed in our study. Staphylococcus was the predominant etiological agent and treatment of endocarditis was more successful when suitable antibiotics were started after culture and sensitivity.

INFECTIVE ENDOCARDITIS IN A RHEUMATOLOGIST’S PRACTICE: ISSUES OF ITS CLINICAL PRESENTATION AND DIAGNOSIS

At present, the problem of infective endocarditis (IE) remains relevant for clinicians of different specialties, including rheumatologists. The distinctive feature of present-day IE is its polyetiological pattern due to a broad spectrum of pathogens. The lecture highlights in detail clinical picture of the disease, laboratory and instrumental findings. It presents current international diagnostic criteria for IE. The obvious clinical polymorphism, subtle symptoms, and monosyndromic onset as masks, all increases the significance of differential diagnosis of IE, in early disease stages in particular. Main approaches to differentiating IE from diseases posing the greatest differentially diagnostic challenges are set forth.

Vascular complications of infective endocarditis

The complications of infective endocarditis (IE) are frequent and severe. Our objectives were to analyze the clinical, paraclinical, and prognostic features of IE vascular complications observed in two cardiology units, in Dakar. Patients and methodsWe retrospectively studied 90 patients presenting with of IE, hospitalized between January 2005 and February 2011. The diagnostic criteria for IE were modified Duke University criteria. We selected in our study population, patients with vascular complications. ResultsSeventeen patients (18.8%) presented with one or more vascular complications of IE: eight male and nine female patients, with a mean age of 28 years. Infective endocarditis occurred on an abnormal valve in 15 cases. We identified 22 vascular lesions: ten neurological complications, seven arterial complications in the limbs, two myocardial infarctions, two cases of pulmonary embolism, and one splenic infarction. The vascular complication revealed an IE in seven cases. The vascular complication occurred during antibiotic treatment, in 15 cases including seven cases before the 14th day, nine of the 17 patients died. Death was related to vascular complications in six cases, in one case it was related to septic shock. ConclusionVascular complications of IE are frequent, the most common are neurological. Their prevention requires early and adequate management of IE.

Diagnosis and Treatment of Infective Endocarditis in Chronic Hemodialysis Patient

To analyze the clinical features of hemodialysis patients complicated by infective endo carditis. The clinical features of six such patients admitted to Peking Union Medical College Hospital during the year 1990 to 2009 were analyzed. All of them were diagnosed based on Chinese Children Diagnostic Criteria for Infective Endocarditis. The average age of the six patients was 52.3 +/- 19.3 years old. Four were males. Vascular accesses at the onset of infective endocarditis were as follows: permanent catheters in three, temporary catheters in two, and arteriovenous fistula in one. Three were found with mitral valve involvement, two with aortic valve involvement, and one with both. Five vegetations were found by transthoracic echocardiography, and one by transesophageal echocardiography. Four had positive blood culture results. The catheters were all removed. Four of the patients were improved by antibiotics treatment, in which two were still on hemodialysis in the following 14-24 months and the other two were lost to follow-up. One patient received surgery, but died of heart failure after further hemodialysis for three months. One was well on maintenance hemodialysis for three months after surgery. Infective endocarditis should be suspected when hemodialysis patients suffer from long-term fever, for which prompt blood culture and transthoracic echocardiography confirmation could be performed. Transesophageal echocardiography could be considered even when transthoracic echocardiography produces negative findings. With catheters removed, full course of appropriate sensitive antibiotics and surgery if indicated could improve the outcome of chronic hemodialysis patients complicated by infective endocarditis.

The value of the Von Reyn and the Duke diagnostic criteria for infective endocarditis in internal medicine practice. A study of 38 cases

Background: The aim of our study was to compare the value of the Von Reyn and the Duke diagnostic criteria for infective endocarditis (IE) in internal medicine practice. Methods: We determined the sensitivity and negative predictive value of these two sets of diagnostic criteria in 38 patients with established infective endocarditis who were followed in two departments of general internal medicine. The patients essentially had subacute endocarditis of the aortic valve (79%) with several systemic manifestations (100%). Microbial documentation included mainly gram-positive cocci (60%). Results: With transthoracic echocardiography (TTE), the sensitivities of the Duke and the Von Reyn criteria were 65% and 35%, respectively, while with transesophageal echocardiography (TEE), these sensitivities were 75% and 35%, respectively. With TTE and TEE, the negative predictive values were 100% for the Duke diagnostic criteria versus only 71% for the Von Reyn criteria. Conclusions: This study confirms that the Duke diagnostic criteria are useful in practice for the management of patients with infective endocarditis followed in internal medicine.

Infective endocarditis: report of a prospective study in an Indian hospital.

Forty-six patients who fulfilled the Duke's clinical diagnostic criteria for infective endocarditis (IE) were evaluated. Thirty-five (76%) patients were below 40 years of age with rheumatic heart disease being the most common underlying heart lesion affecting 26 (56%). An obvious predisposing cardiac lesion could not be ascertained in 22%. Blood culture positivity was 44% with streptococcus heading the list. The incidence of the staphylococcal (25%) and gram negative bacillary endocarditis (15%) were found to be increasing. Streptococci were susceptible to penicillin with minimum bactericidal concentration: minimum inhibitory concentration within acceptable limits. However, the appearance of methicillin resistant staphylococcus aureus and high level gentamicin resistant enterococcus as aetiological agents of infective endocarditis were found to add to the complexity of the problem. With the emergence of drug-resistant organisms as causative agents of IE, whenever medical therapy is the primary method of treatment of this condition, the selection of antibiotics should depend upon extensive in vitro testing and in vivo monitoring of clinical efficacy.

Infective endocarditis in children — incidence, pattern, diagnosis and management in a developing country

Background: In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high. Objective: Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome. Setting: A tertiary referral center for paediatric and adult cardiology. Patients and methods: All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Duke’s criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases. Results: Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9±4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients). Conclusions: The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.

An Assessment of the Current Diagnostic Criteria for Infective Endocarditis

A firm diagnosis of infective endocarditis is difficult to establish. Clinicians often face a decision-making dilemma about whether to treat a patient presenting with some features that suggest endocarditis. This article summarizes both the previous and the recently proposed criteria for the diagnosis of infective endocarditis, and reviews the efficacy of the new criteria. The authors also discuss the experience at The Toronto Hospital, Toronto, Ontario, with this disease, paying specific attention to the application of the new criteria in the diagnostic process.