Duke Criteria For Infective Endocarditis Research Articles

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.

Clinicopathological differences between Bartonella and other bacterial endocarditis-related glomerulonephritis - our experience and a pooled analysis.

Although Staphylococcus aureus is the leading cause of acute infective endocarditis (IE) in adults, Bartonella spp. has concomitantly emerged as the leading cause of "blood culture-negative IE" (BCNE). Pre-disposing factors, clinical presentation and kidney biopsy findings in Bartonella IE-associated glomerulonephritis (GN) show subtle differences and some unique features relative to other bacterial infection-related GNs. We highlight these features along with key diagnostic clues and management approach in Bartonella IE-associated GN. We conducted a pooled analysis of 89 cases of Bartonella IE-associated GN (54 published case reports and case series; 18 published conference abstracts identified using an English literature search of several commonly used literature search modalities); and four unpublished cases from our institution. Bartonella henselae and Bartonella quintana are the most commonly implicated species causing IE in humans. Subacute presentation, affecting damaged native and/or prosthetic heart valves, high titer anti-neutrophil cytoplasmic antibodies (ANCA), mainly proteinase-3 (PR-3) specificity, fastidious nature and lack of positive blood cultures of these Gram-negative bacilli, a higher frequency of focal glomerular crescents compared to other bacterial infection-related GNs are some of the salient features of Bartonella IE-associated GN. C3-dominant, but frequent C1q and IgM immunofluorescence staining is seen on biopsy. A "full-house" immunofluorescence staining pattern is also described but can be seen in IE -associated GN due to other bacteria as well. Non-specific generalized symptoms, cytopenia, heart failure and other organ damage due to embolic phenomena are the highlights on clinical presentation needing a multi-disciplinary approach for management. Awareness of the updated modified Duke criteria for IE, a high index of suspicion for underlying infection despite negative microbiologic cultures, history of exposure to animals, particularly infected cats, and use of send-out serologic tests for Bartonella spp. early in the course of management can help in early diagnosis and initiation of appropriate treatment. Diagnosis of IE-associated GN can be challenging particularly with BCNE. The number of Bartonella IE-associated GN cases in a single institution tends to be less than IE due to gram positive cocci, however Bartonella is currently the leading cause of BCNE. We provide a much-needed discussion on this topic.

Intraoperative Cell Savage, Infection and Organ Failure in Infective Endocarditis Patients-A Retrospective Single Center Evaluation.

Surgery is indicated in about 50% of infective endocarditis patients, and bleeding or the transfusion of blood a common finding. The intraoperative use of cell salvage may reduce the perioperative transfusion requirement, but its use is limited in the underlying disease. In this retrospective study, we therefore evaluated n = 335 patients fulfilling the modified Duke criteria for infective endocarditis characterized by the use of intraoperative cell salvage with autologous blood retransfusion. Inflammation markers and organ dysfunction, including catecholamine dependency, were evaluated by using linear regression analysis. Between 2015 and 2020, 335 patients underwent surgery for left-sided heart valve endocarditis. Intraoperative cell salvage was used in 40.3% of the cases, especially in complex scenarios and reoperation. Intraoperative cell salvage significantly altered the white blood cell count after surgery. On average, leucocytes were 3.0 Gpt/L higher in patients with intraoperative cell salvage compared to patients without after adjustment for confounders (95% CI: 0.39-5.54). Although the difference in WBC was statistically significant, i.e., higher in the ICS group compared to the no-ICS group, this difference may be clinically unimportant. Organ dysfunction, including hemodynamic instability and lactate values, were comparable between groups. In conclusion, intraoperative cell salvage enhanced the re-transfusion of autologous blood, with minor effects on the postoperative course of inflammatory markers, but was not associated with increased hemodynamic instability or organ dysfunction in general. The restriction of intraoperative cell salvage in surgery for infective endocarditis should be re-evaluated, and more prospective data in this topic are needed.

Neurologic complications of infective endocarditis in children.

To define the frequency and characteristics of acute neurologic complications in children hospitalised with infective endocarditis and to identify risk factors for neurologic complications. Retrospective cohort study of children aged 0-18years hospitalised at a tertiary children's hospital from 1 January, 2008 to 31 December, 2017 with infective endocarditis. Sixty-eight children met Duke criteria for infective endocarditis (43 definite and 25 possible). Twenty-three (34%) had identified neurologic complications, including intracranial haemorrhage (25%, 17/68) and ischaemic stroke (25%, 17/68). Neurologic symptoms began a median of 4.5days after infective endocarditis symptom onset (interquartile range 1, 25days), though five children were asymptomatic and diagnosed on screening neuroimaging only. Overall, only 56% (38/68) underwent neuroimaging during acute hospitalisation, so additional asymptomatic neurologic complications may have been missed. Children with identified neurologic complications compared to those without were older (48 versus 22% ≥ 13years old, p = 0.031), more often had definite rather than possible infective endocarditis (96 versus 47%, p < 0.001), mobile vegetations >10mm (30 versus 11%, p = 0.048), and vegetations with the potential for systemic embolisation (65 versus 29%, p = 0.004). Six children died (9%), all of whom had neurologic complications. Neurologic complications of infective endocarditis were common (34%) and associated with mortality. The true frequency of neurologic complications was likely higher because asymptomatic cases may have been missed without screening neuroimaging. Moving forward, we advocate that all children with infective endocarditis have neurologic consultation, examination, and screening neuroimaging. Additional prospective studies are needed to determine whether early identification of neurologic abnormalities may direct management and ultimately reduce neurologic morbidity and overall mortality.

Neurological complications in children with infective endocarditis: Incidence, risk factors, and outcome: A 10-year single-center experience.

Background and ObjectiveDespite improvement in medical management, infective endocarditis (IE) remains a serious disease that may affect children with and without preexisting cardiac conditions with significant morbidity and mortality. Neurological complications of IE represent the worst with guarded prognosis. The aim of this study is to describe the incidence, etiology, characteristics, risk factors, and outcome of children with neurological complications associated with IE.Material and methodsA retrospective cohort study was conducted from 2009 to 2019 where all pediatric patients who fulfilled the modified Duke criteria for IE were included. We divided the cases into 2 groups: IE with neurological complications and IE without neurological complications control group. We compared the two groups statistically and analyzed the results.ResultsWe identified 31 (17 male, 14 female) patients with IE. Neurological complications occurred in 7/31 (23%) patients, mainly in the form of a stroke. Gram-positive microbes were the main causative agents for IE (52%) followed by gram-negative (14%), then fungal organisms (3%). Univariate analysis identified the following risk factors for neurological complications: lower body weight, higher C- reactive protein (CRP) level, and left-sided valvular lesions with P values of (0.0003, 0.0001, and 0.04), respectively.Although mortality was higher in the neurological complications group, it was 43% in comparison to 21% in the control group and it did not reach statistical significance (P = .49). Large vegetation size (more than 10 mm) was seen in 57% of patients with neurological complications as compared to 16% in the control group (P = .052).ConclusionNeurological complications occurred in almost a quarter of children with IE. Possible risk factors include lower body weight, left-sided valvular lesion, and higher levels of inflammatory markers (CRP). Stroke was the most common neurological complication encountered with possible increased risk of mortality.

Abstract 13434: Improved Diagnostic Performance of Contemporary Transesophageal Echocardiography With Three-dimensional Imaging for Infective Endocarditis

Introduction: Infective endocarditis (IE) is associated with high morbidity and mortality. Conventionally, a repeat transesophageal echocardiogram (TEE) is necessary if the first TEE is negative, and there is high clinical suspicion. We aimed to investigate the diagnostic performance of contemporary TEE for IE. Hypothesis: We hypothesize that with advancements in TEE imaging, including three-dimensional (3D) imaging, the diagnostic performance of TEE for IE would be improved. Methods: Patients who had two or more TEEs at our center, within 6 months, for evaluation of IE in 2011 (pre-3D imaging) and 2019 (post-3D imaging) were included. Patients not meeting the Duke criteria for IE (n=899) were excluded. The primary endpoint was the sensitivity of TEE to detect IE. TEE sensitivity was also compared among the different subtypes of IE (native valve, prosthetic valve, device-related, central line-related, and aortic prosthetic graft-related). Results: 242 patients were included: 70 in 2011 and 172 in 2019. In 2011, there were more smokers and a lower rate of pacing devices; otherwise, there were no significant differences in baseline characteristics, including intravenous drug use. The sensitivity of the initial TEE for IE was 85.7% in 2011, improving significantly to 95.3% in 2019 (p=0.01). The improved diagnostic performance in 2019 was mainly driven by the improved detection of prosthetic valve IE (70.8% vs. 93.7%, p=0.009). There were no significant differences for the other subtypes of IE (Figure). In 2019, patients had a higher rate of IE diagnosis within 15 days of index admission, which did not reach statistical significance (n=161, 93.6% vs. n=62, 88.6% in 2011, p=0.19). Kaplan Meier analysis demonstrated that patients in 2019 had a higher rate of procedures for endocarditis (p=0.01). Conclusions: Contemporary TEE imaging including 3D technology improved the detection of IE on the initial TEE, mainly driven by improved detection of prosthetic valve IE.

A RARE PRESENTATION OF GROUP C STREPTOCOCCUS ENDOCARDITIS WITH DIFFUSE SEPTIC EMBOLI

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Group C beta-hemolytic Streptococcus (GCS) typically causes skin and soft tissue infections, pharyngitis, and wound infections. However, the incidence of bacteremia from GCS has increased significantly over the past decade1. Most cases of GCS bacteremia and complications including endocarditis, meningitis, and septic arthritis occur in older adults with underlying chronic illnesses2. We present the unusual case of GCS endocarditis with diffuse septic emboli causing multi-organ failure in a young female. CASE PRESENTATION: A 24-year-old female with a history of intravenous drug use was admitted with altered mental status after IV drug use. On presentation, patient was afebrile with no leukocytosis, and examination was significant for tachycardia, extreme agitation, hyperalgesia, and hallucinations. Preliminary workup revealed thrombocytopenia, acute kidney injury, acute liver injury, and troponinemia. Chest radiographs showed cardiomegaly with concern for mild pulmonary edema. Toxicology screen was positive for amphetamines and cannabinoids but negative for opioids. Echocardiogram revealed a 1.9cm x 1.8cm echodensity attached to the basal free wall of the right ventricle near the level of the tricuspid valve. Blood cultures were positive for GCS, meeting 2 major Duke criteria for infective endocarditis. Her clinical course was complicated by septic shock and acute hypoxic respiratory failure requiring intubation. Repeat chest imaging revealed diffuse patchy airspace opacities with superimposed interstitial predominance. Computed tomography of the chest showed a bronchovascular distribution of wedge-shaped consolidative opacities scattered diffusely throughout bilateral lungs. Imaging findings also included hepatosplenomegally and evidence of embolization to the kidneys. She showed clinical improvement with intravenous antibiotics and mechanical ventilation and is under evaluation by cardiothoracic surgery for valve repair and vegetation excision. DISCUSSION: Though GCS bacteremia and endocarditis are typically seen in older adults with comorbidities, this case highlights the rapid progression and clinical sequelae of GCS bacteremia in a young female with IV drug use. Tricuspid valve vegetations are commonly seen in IV drug use-associated endocarditis, however a vegetation in the right ventricle arising from the basal free wall is exceedingly rare. The location of the vegetation likely contributed greatly to the rapid showering of emboli and severity of symptoms in this case. CONCLUSIONS: Though GCS is not an organism frequently associated with IV drug use, it should now be considered given the rising incidence of GCS bacteremia and the severity of disease it may cause1. Reference #1: Lother S, Jassal D, Lagacé-Wiens P, Keynan Y. Emerging Group C and Group G Streptococcal Endocarditis: A Canadian Perspective. Int J Infect Dis 2017; 65: 128-132 Reference #2: Berenguer J, Sampedro I, Cercenado E, et. al. Group-C Beta-Hemolytic Streptococcal Bacteremia. Diagn Microbiol Infect Dis 1992; 15(2): 151-155 DISCLOSURES: No relevant relationships by Gold Adkins, source=Web Response No relevant relationships by Aria Bryan, source=Web Response No relevant relationships by Shine Raju, source=Web Response No relevant relationships by Pallavi Sharma, source=Web Response No relevant relationships by Catalina Teba, source=Web Response

The changing landscape of infective endocarditis in South Africa.

Little is known about the current clinical profile and outcomes of patients with infective endocarditis (IE) in South Africa (SA). To provide a contemporary and descriptive overview of IE in a representative SA tertiary centre. We conducted a retrospective review of the records of patients admitted to Groote Schuur Hospital, Cape Town, between 2009 and 2016 fulfilling universal criteria for definite or possible IE, in search of demographic, clinical, microbiological, echocardiographic, treatment and outcome information. A total of 105 patients fulfilled the modified Duke criteria for IE. The median age of the cohort was 39 years (interquartile range (IQR) 29 - 51), with a male preponderance (61.9%). The majority of the patients (72.4%) had left-sided native valve endocarditis, 14.3% had right-sided disease, and 13.3% had prosthetic valve endocarditis. A third of the cohort had rheumatic heart disease. Although 41.1% of patients with left-sided disease had negative blood cultures, the three most common organisms cultured in this subgroup were Staphylococcus aureus (18.9%), Streptococcus spp. (16.7%) and Enterococcus spp. (6.7%). Participants with right-sided endocarditis were younger (29 years, IQR 27 - 37) and were mainly intravenous drug users (73.3%), and the majority cultured positive for S. aureus (73.3%) with frequent septic pulmonary complications (40.0%). The overall in-hospital mortality was 16.2%, with no deaths in the group with right-sided endocarditis. Predictors of death in our patients were heart failure (odds ratio (OR) 8.16, 95% confidence interval (CI) 1.77 - 37.70; p=0.007) and age &gt;45 years (OR 4.73, 95% CI 1.11 - 20.14; p=0.036). Valve surgery was associated with a reduction in mortality (OR 0.09, 95% CI 0.02 - 0.43; p=0.001). IE remains an important clinical problem in a typical teaching tertiary care centre in SA. In this setting, it continues to affect mainly young people with post-inflammatory valve disease and congenital heart disease. The in-hospital mortality associated with IE remains high. Intravenous drug-associated endocarditis caused by S. aureus is an important IE subset, comprising ~10% of all cases, which was not reported 15 years ago, and culture-negative endocarditis remains highly prevalent. Heart failure in IE carries a significant risk of death and needs a more intensive level of care in hospital. Finally, cardiac surgery was associated with reduced mortality, with the largest impact in patients with heart failure.

99mTc-Besilesomab-SPECT/CT in Infectious Endocarditis: Upgrade of a Forgotten Method?

Infective endocarditis displays a serious condition with high mortality rates. Establishing a reliable diagnosis can be challenging. This study evaluates granulocyte imaging with 99mTc-Besilesomab-SPECT/CT in order to determine the clinical value of the method and its possible redefinition through the addition of hybrid imaging. The study comprises 26 consecutive patients with suspected infectious endocarditis or prosthetic valve infection that underwent 99mTc-Besilesomab-SPECT/CT in our facility between December 2016 and September 2018. 99mTc-Besilesomab-SPECT/CT images were reviewed by two independent and blinded observers and results were evaluated by transesophageal echocardiography (TEE) and blood culture results as well as by pathological, bacteriological, and clinical findings. Target-to-Background-Ratios were calculated for semi-quantitative analysis. 13/26 patients were in a post-surgical stage. 99mTc-Besilesomab-SPECT/CT was positive in 6 cases. All 6 cases were true positive confirmed by pathological or clinical findings according to the modified Duke Criteria for infective endocarditis. Remaining 19/26 cases were true negative. Target-to-Background ratios were significantly higher in patients that were visually scored positive compared to negative cases. Inter-observer agreement was very good of deciding whether a scan was positive or negative. Sensitivity of 99mTc-Besilesomab-SPECT/CT was 86–100% and specificity was 100%. 99mTc-Besilesomab-SPECT/CT is a useful imaging method for the diagnosis of endocarditis, especially in difficult cases with prosthetic valves or cardiac devices and inconclusive findings in echocardiography. The added value of SPECT/CT was mainly finding and localizing increased uptake at a certain valve, prosthesis, or device cable.

1021. Repeat Infective Endocarditis (rIE) in Persons Who Inject Drugs (PWID)

BackgroundInjection drug use (IDU) is a major risk factor for infective endocarditis (IE). Rates of IE have recently increased in the US concurrent with the opioid crisis. Although IDU-related IE is well described, few data exist on repeat IE (rIE) in persons who inject drugs (PWID).MethodsPatients ≥18 years old seen at Wake Forest Baptist Medical Center from 2004–2017 with an ICD-9 or -10 diagnosis of IE who met Duke criteria for IE and who self-reported IDU in the 3 months prior to admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after the diagnosis of the first episode, was then reviewed.ResultsOf the 94 PWID with IE, 22 (23.4%) experienced rIE (19 re-infections, three relapses). All patients were Caucasian, 50% were male, and 68.2% lived in rural areas; the median age was 30. All 22 patients resumed IDU after their first episode of IE. The mean duration from completion of antibiotics for the prior IE episode to admission with rIE was 257.5 days; the episode of rIE occurred within 1 year in 17 patients (77.3%). On repeat admission, those with rIE had a Pitt bacteremia score of 3.0 and an APACHE II score of 13.1. Fever and bacteremia persisted for an average of 5.6 days and 2.6 days, respectively. S. aureus was the cause of rIE in 54.5% of patients and the tricuspid valve (TV) was involved in 77.3% of cases. Valve surgery occurred in 22.7% of patients. Mean length of stay was 25.3 days and mean duration of antibiotic therapy was 32.1 days. Seven patients (31.8%) died during the rIE hospitalization and another died within 12 months after discharge resulting in a 1-year mortality of 36.3%. Compared with their first episode of IE, rIE patients had higher admission Pitt bacteremia (3.0 vs. 1.5, P = 0.07) and APACHE II scores (13.1 vs. 9.5, P = 0.18), fewer S. aureus infections (54.5% vs. 95.4%, P = 0.01), similar TV involvement (77.3% vs. 72.7%, P = 1), and less frequent surgery (22.7% vs. 59.1%, P = 0.06).ConclusionrIE is common in PWID with most episodes occurring within 1 year of the initial episode. Reinfection is more frequent than relapse. The microbiology of rIE is more varied than first episode IE in PWID with S. aureus being less frequently isolated. Illness severity is high, hospitalizations are prolonged, and 1-year mortality is significant. More effective strategies for preventing rIE in PWID are needed.Disclosures J. Peacock, Pfizer: Shareholder, Owns common stock in Pfizer which was inherited and held in a trust.

1075. A Retrospective Comparison of Native Valve Endocarditis and Prosthetic Valve Endocarditis in a Large Tertiary Care Teaching Hospital From 2007 to 2015

BackgroundStudies comparing native valve and prosthetic valve endocarditis (NVE and PVE) have mixed findings on the risk factors and outcomes between the two cohorts. This retrospective review of infective endocarditis (IE) at a teaching hospital in the United States aims to compare the clinical and microbiological features between NVE and PVE.MethodsPatients were retrospectively identified from 2007 to 2015 using appropriate IE-related ICD-9 codes. Cases that met definite Modified Duke Criteria for IE were further classified as either PVE or NVE, and were reviewed for epidemiology, causative organism(s), affected valves and associations, risk factors, dental procedures in the past 6 months, and 30-day mortality.ResultsA total of 363 admissions met criteria for definite endocarditis, with 261 NVE cases and 59 PVE cases. Forty-three cases that were either associated with an infection involving both native and prosthetic valves or intracardiac devices were omitted from this study. Most risk factors, such as hemodialysis and intravenous drug use, did not show any significant difference amongst the two groups. IE involving the aortic valve as well as a previous history of IE were more likely to be seen in PVE (both P < 0.0001). Dental procedures done in the preceding 6 months before IE admission were more likely to be associated with PVE than NVE (P = 0.0043). PVE showed a higher likelihood of 30-day mortality compared with NVE (P = 0.067). The causative organisms of PVE were more likely to be caused by common gut pathogens such as Klebsiella and Enterobacter species.ConclusionPVE cases had a significantly higher chance of involving the aortic valve as well as having a history of IE. PVE cases were also significantly more likely to be associated with a dental procedure done in the preceding 6 months than with the NVE cases. This implies that patients with prosthetic valves, who are currently covered under the 2007 AHA guidelines to receive prophylaxis prior to dental procedures, are still at a high risk of developing PVE. It may be prudent to reconsider adding a post-procedure dose of antibiotics, instead of a single preprocedure dose, to extend the protection of this high-risk population with prosthetic valves. Furthermore, PVE cases showed higher rates of 30-day mortality compared with NVE with near significance, which is likely multifactorial.Disclosures All authors: No reported disclosures.

1074. Management and Outcomes of Infective Endocarditis Due to Nutritionally Variant Streptococci

BackgroundNutritionally variant streptococci (NVS) are an infrequent cause of infective endocarditis (IE) and management recommendations are based on weak levels of evidence largely derived from case reports, small case series, and animal models of experimental endocarditis. Moreover, taxonomic changes have led to some confusion in designation of these organisms.MethodsWe retrospectively collected and analyzed data from 33 patients with NVS IE from 1970 to 2017. Only patients who met modified Duke Criteria for IE were included.ResultsMean patient age was 55 years and 61% were males. The most common comorbidities included diabetes mellitus (12%), malignancy (3%), heart failure (16%), coronary artery disease (25%), and chronic liver disease (9%). Predisposing valve abnormalities included rheumatic heart disease (11%), bicuspid aortic valve (22%), transplant valvulopathy (3%), mitral valve prolapse (3%), and congenital heart disease (11%). Cultures were reported as NVS (70%), Granulicatella species (18%) and Abiotrophia species (12%). Echocardiogram findings included vegetations (67%), new regurgitation (55%), perivalvular abscess (3%), mitral valve prolapse (3%), and ruptured mitral valve chordae (3%). Both prosthetic (26%) and native valve IE (74%) was seen, and the valves involved were aortic (37%), mitral (50%) and both aortic and mitral (13%). Complications were seen in 27% of patients, including heart failure (17%), splenic infarct (11%), stroke (8%), mycotic aneurysm (3%), and glomerulonephritis (2%). In vitro susceptibility to penicillin, ceftriaxone, and vancomycin was 88%, 80%, and 100%, respectively. The majority (77%) of patients were treated with a combination of β-lactam and aminoglycoside. Median duration of treatment was 33 days. Surgery was performed in 50% of patients with no significant difference in survival between those who were treated with combined medical/surgical treatment and those treated with medical therapy alone. Overall survival at 1, 4, and 10 years was 93%, 83%, and 66%, respectively.ConclusionIE due to NVS is a rare entity and is associated with a high rate of serious complications and may involve multiple valves. Long-term, two-thirds of the patients survived more than 10 years.Disclosures All authors: No reported disclosures.

Repeat Infective Endocarditis in Persons Who Inject Drugs: "Take Another Little Piece of my Heart".

BackgroundInjection drug use (IDU) is a major risk factor for infective endocarditis (IE). Few data exist on repeat IE (rIE) in persons who inject drugs (PWID).MethodsPatients ≥18 years old seen at Wake Forest Baptist Medical Center from 2004 to 2017 who met Duke criteria for IE and who self-reported IDU in the 3 months before admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after diagnosis of the first episode, was then reviewed.ResultsOf the 87 PWID who survived their first episode of IE, 22 (25.3%) experienced rIE and 77.3% had rIE within a year of the first episode. All patients who experienced rIE resumed IDU between episodes of IE. Of the patients with rIE, 54.5% had an infection caused by S. aureus and 22.7% required surgical intervention. Mortality at 1 year was 36.3%. Compared with their first IE episode, patients with rIE had fewer S. aureus infections (P = .01). Compared with PWID who experienced single-episode IE, intravenous prescription opioid use (P = .01), surgery (P < .01), tricuspid valve involvement (P = .02), and polymicrobial infection (P = .03) occurred more often during first episodes of IE in individuals who then developed rIE.ConclusionsrIE is common among IDU-related IE and confers a high 1-year mortality rate. The microbiology of rIE is varied, with S. aureus being less frequently isolated. More studies on modification of social and clinical risk factors are needed to prevent rIE.

A retrospective epidemiologic study to define risk factors, microbiology, and clinical outcomes of infective endocarditis in a large tertiary-care teaching hospital.

Objective:This study aims to define risk factors as well as their association with microbiology and clinical outcomes in a large US infective endocarditis population.Methods:Hospital records were searched for appropriate infective endocarditis–related ICD codes from 16 July 2007 to 13 August 2015. A total of 363 cases were retrospectively identified that met definite Modified Duke Criteria for infective endocarditis and were analyzed by age group, causative organism, and associated risk factors for use of valvular surgical intervention, 30/90/180-day mortality after admission, and embolic phenomena.Results:Chronic hemodialysis was the most common risk factor (26.7% of cases). Of all age groups, those aged 78+ years had the lowest 30-day mortality but those aged 58–77 years had the highest mortality (p = 0.039). Staphylococcus aureus was the most prevalent causative organism. Those aged 78–97 years were more likely to have enterococcal infective endocarditis than those aged 18–27 years (p = 0.0144). Chronic hemodialysis associated infective endocarditis was more likely to be caused by coagulase-negative staphylococcus (p = 0.0121) and have a higher 30-day mortality (p = 0.141) than intravenous drug use associated infective endocarditis. Intravenous drug use and chronic hemodialysis were similarly likely to be caused by S. aureus. Intravenous drug use associated infective endocarditis was more likely to be caused by viridans group streptococci (p = 0.0001). Fungal infective endocarditis was most likely to embolize. Chronic hemodialysis patients were less likely to undergo valvular surgery (p = 0.001) and those with chronic hemodialysis who did had lower mortality than those only managed medically that did not reach statistical significance (p = 0.2991). Infective endocarditis caused by coagulase-negative staphylococci had the greatest 30-day mortality at 31.3% but did not reach statistical significance over all other causative organisms (p = 0.060).Conclusion:In our infective endocarditis population, S. aureus is the predominant causative organism. Chronic hemodialysis is the most common risk factor present in infective endocarditis populations and has greater association with coagulase-negative staphylococci and 30-day mortality. Intravenous drug use had the lowest mortality among risk factors with a similar proportion of S. aureus infective endocarditis compared to chronic hemodialysis but a higher proportion of viridans group streptococci infective endocarditis cases. Further study will need to be performed on prevention and treatment of infective endocarditis in chronic hemodialysis patients.

Comparison of Outcome of Possible Versus Definite Infective Endocarditis Involving Prosthetic or Bioprosthetic Heart Valves

The objectives of this study were to describe and compare the clinical characteristics and outcomes of patients with definite and possible infective endocarditis (IE) involving prosthetic heart valve, and to identify prognostic factors for long-term mortality, using data from an unselected cohort of consecutive patients. We studied data from 133 consecutive patients with IE involving prosthetic heart valve seen in an academic institution between 1990 and 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (n = 47, 35%) and patients with definite IE (n = 86, 65%). Overall, 55 patients died over a mean ± SD follow-up of 3.6 ± 4.1 years (median 1.8, interquartile range 4.4 years). Patients with definite IE had a higher risk of death (hazard ratio [HR] 2.21, 95% confidence interval [CI] 1.20 to 4.17 p = 0.01). Independent predictors of long-term mortality were increasing age (HR 1.05, 95% CI 1.02 to 1.08, p = 0.002), Staphylococcus aureus infection (HR 3.40, 95% CI 1.00 to 11.76; p = 0.05), infection with unknown microorganism (HR 12.50, 95% CI 2.97 to 52.63; p = 0.0006), and definite IE (HR 8.70, 95% CI 3.55 to 21.28; p <0.0001), whereas infection on pacemaker or defibrillator (HR 0.30, 95%CI 0.10 to 0.87; p = 0.03) was associated with a better prognosis. Patients with definite IE and those with possible IE who underwent surgery had a nonsignificantly better prognosis than their counterparts with no surgery. In conclusion, patients with definite IE (Duke criteria) on a prosthetic heart valve independently had a worse prognosis than those with possible IE.

Comparison of Outcome of Possible Versus Definite Infective Endocarditis Involving Native Heart Valves

There are very few data on the prognosis of possible versus definite infective endocarditis (IE). We studied data from 365 consecutive patients with IE involving native heart valve seen in an academic institution from 1990 to 2012. Patients were classified according to the modified Duke criteria for IE: patients with possible IE (n= 101, 28%) and those with definite IE (n= 264, 72%). Patients with possible IE were older than those with definite IE (66 ± 15 vs 62 ± 16, p= 0.05). A causative microorganism was identified in 66% of patients with possible IE versus all patients with definite IE (p <0.0001) and only 41% had major echocardiographic criteria (vs 100%; p <0.0001). Overall, 139 patients died over a mean±SD follow-up of 3.9 ± 4.5years (median 2.2, interquartile range 5.9years). Patients with possible and definite IE had a similar risk of death. Independent predictors of long-term mortality were increasing age (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1.01 to 1.04; p= 0.0009), vegetation length >15mm (HR 1.87, 95% CI 1.14 to 3.06; p=0.01), and stroke (HR 4.10, 95% CI 1.84 to 9.17; p= 0.0006), whereas infection of mitral valve (HR 0.57, 95% CI 0.34 to 0.94; p= 0.03) and surgery (HR 0.43, 95% CI 0.19 to 0.99; p=0.05) were associated with a better prognosis. Patients with definite IE and those with possible IE who did not undergo surgery had a worse prognosis than their counterparts with surgery. In conclusion, unselected patients with possible IE (Duke criteria) had a similar prognosis than those with definite IE.

Fever and Renal Failure in a Child With DiGeorge Syndrome and Tetralogy of Fallot

The patient is a 9-year-old male with DiGeorge syndrome and tetralogy of Fallot; he underwent cardiac repair at 7 months. Seven years later, in early 2012, he underwent a pulmonary artery to right ventricle conduit replacement with a tricuspid valve repair. In November 2013, he developed increased fatigue with abdominal pain and intermittent emesis and was ultimately admitted in February 2014 with progressive cough and low-grade fevers. His initial vital signs were the following: temperature 101.7°F, blood pressure 119/66, heart rate 109, respiratory rate 13, and O2 saturation 97% on room air. Examination was notable for nontoxic appearance, III/VI holosystolic murmur at the left upper sternal border, crackles at lung bases, and 1+ edema in the bilateral lower extremities. His liver edge was 3–4 cm below the right costal margin with a palpable spleen tip. There was no lymphadenopathy or rashes or stigmata of infective endocarditis, such as Janeway lesions or Osler nodes. The patient’s white blood cell count was 7300 cells/mm (73% neutrophils, 16% lymphocytes, and 10% monocytes), his hemoglobin was 4.9 g/dL, and his platelet count was 90,000 cells/mm. Blood urea nitrogen and creatinine were 84 mg/mL and 5.3 mg/dL, respectively. Hemolysis laboratory results (haptoglobin, lactate dehydrogenase) were normal, and a reticulocyte count was elevated to 4.3% (0.5–2.3% normal). There was mild coagulopathy (international normalized ratio 1.4), hypocomplementemia with C3 47 mg/dL (93– 203 mg/dL normal), and the erythrocyte sedimentation rate was elevated to 100 mm/h (0–15 mm/h normal). Urinalysis showed 3+ blood, 1+ protein, negative nitrites and leukocyte esterase, positive casts, and crystals. A renal ultrasound scan showed enlarged echogenic kidneys and a chest radiograph revealed marked cardiomegaly with bibasilar atelectasis. A transthoracic echocardiogram showed a thickened tricuspid valve, concerning for vegetations, with moderately increased tricuspid regurgitation. Vegetations were also present in the right ventricle to pulmonary artery conduit with mild aortic insufficiency. The patient met Duke criteria for infective endocarditis (IE) with 1 major criterion, based on echocardiographic findings, and 3 minor criteria, including predisposition for endocarditis, fever 38.0°C, and evidence of immunologic phenomena as demonstrated by glomerulonephritis. Five high-volume blood cultures (including a fungal isolator) were obtained prior to initiation of antibiotics. After initiation of vancomycin, gentamicin, and cefepime, the patient quickly defervesced. No evidence of embolic events was seen on chest computed tomography scan, abdominal ultrasound, or ophthalmologic examination. On exposure history, the patient was born in the United States and lived in California before moving to Mexico at age 3. He returned briefly to the United States at age 7 for his second cardiac surgery, but otherwise was living on a farm near Guadalajara, Mexico where he had routine contact with farm animals. He denied participation in animal birthing or consuming raw meat, but frequently ate homemade queso fresco. He returned to live in California Central Valley in December 2013.

Inflammatory parameters and prediction of prognosis in infective endocarditis

BackgroundProcalcitonin (PCT) is widely used in critically ill patients to diagnose clinically significant infection and sepsis. Aim of this study was to evaluate the prognostic value of PCT in comparison to white blood cell count (WBC) and C-reactive protein (CRP) for clinical outcome and its correlation with microbiological etiology in patients with infective endocarditis (IE).MethodsA retrospective single-center analysis was performed from 2007 till 2009. All patients were diagnosed having IE according to Duke standard criteria. Before starting antibiotic therapy, WBC, CRP and PCT were measured and blood cultures were taken for microbiological diagnosis of the etiological pathogen. Patients were followed up during in-hospital stay for poor outcome, defined as death or serious complications due to IE.ResultsDuring the study period 50 patients (57 ± 17 years, 72% male) fulfilling Duke criteria for IE were identified. In all patients PCT measurements before start of antibiotic therapy were available. In ROC analysis, a cut-off for PCT > 0.5 ng/mL was most accurate for the prediction of poor outcome with a sensitivity of 73% and specificity of 79%, a positive predictive value of 79% and a negative predictive value of 73%. Patients with a PCT > 0.5 ng/mL had an odds ratio of 12.8 (95% CI 2.5 – 66.2) for finding Staphylococcus aureus in blood cultures.ConclusionsFor the first time, this study shows that in IE, an initial value of PCT > 0.5 ng/mL is a useful predictor of poor outcome, i.e. death or serious infectious complications. PCT > 0.5 ng/mL should raise the suspicion of Staphylococcus aureus as the etiological pathogen, whereas PCT levels < 0.5 ng/mL make staphylococcal infection unlikely.

147: Infective endocarditis in Tunisia: A changing profile?

Since the first description of infective endocarditis (IE), the profile of the disease has evolved continuously with stable incidence. To update information gained on the epidemiology profile of IE in a Tunisian high-volume tertiary care center This was a descriptive retrospective study of patients treated for IE from January 2001 to December 2010. The patients were divided in two groups according to the date of diagnosis of IE: group 1 (from January 2001 to June 2006) and group 2 (from June 2006 to December 2011). These groups were compared for epidemiologic factors and microbiological differences. A total of 297 patients admitted during the study period met the modified Duke criteria for IE. The comparison of demographic and microbiological characteristics of IE cases over time between the results of the two groups showed that the annual incidence of IE was stable. The sex incidence rates of IE, in particular, incidence among men was relatively stable across the study period and ranged from 60% in 2001-2006 to 58% in 2006-2010, also there was no significant increase in incidence among women (P=ns). Among incident cases, there was a significant increasing age on presentation, with median age increasing from 39.5 years in 2001-2006 to 51.5 years in 2006-2010 (P=0.05). There were no statistically significant decreases in the proportions of cases affecting the aortic valve (P=0.4) and in IE due to oral streptococci (P= ns) over time. Also there was no significant increase in the incidence of Staphylococcus IE. However, the incidence of IE with negative blood culture has remained stable and continues to be high, nearing 50%. The rate of rheumatic heart disease as an underlying heart disease was stable over time. However, the standardized incidence of IE has increased in patients with prosthetic valves (P= ns). Overall in-hospital mortality rate decreased from ((18.6% in 2001-2006 vs 14.6% in 2006-2010. This study has shown that the annual incidence of IE is stable in Tunisia. However, profound changes in the epidemiological profile of this disease have not been noted in our population.

Cardiac implantable electronic device-related endocarditis: A 12-year single-centre experience

The incidence of cardiac implantable electrical device endocarditis (CIEDE) is increasing, but CIEDE remains a relatively poorly described infection. This case series describes our experience of the condition at a tertiary referral centre in London over a 12-y period. We identified cases using an endocarditis database containing prospectively collected clinical and microbiological information. We also used data recorded in an electronic database of all cardiac implantable electrical device-related procedures. Thirty cases of CIEDE were treated at our institution during the study period. Presentation was most commonly with fever, and 93% of our patients had positive blood cultures. Vegetations were identified on echocardiography in only 70% of patients, although a transoesophageal echocardiogram (TOE) was performed in only half of the cases. Sixty-seven percent of our cases were defined as definite endocarditis according to the modified Duke criteria for infective endocarditis. Twenty-three patients underwent percutaneous explantation of their infected CIED (including 6 patients with vegetations greater than 10 mm in diameter), while 5 underwent surgical explantation. The overall in-hospital mortality was 17%. Our data confirm the life-threatening nature of CIEDE in a UK population. In addition, our experience suggests that percutaneous extraction of devices with large adherent vegetations may be safe, and that the selective use of TOE may not compromise outcomes. Lastly, we show that the modified Duke criteria do not perform very well with this condition, suggesting a need for specific, validated criteria for diagnosing CIEDE.