Endocarditis In Patients Research Articles

Abstract 16259: Gemella Morbillorum Infective Endocarditis: A Systematic Review

Introduction: Gemella morbillorum is a facultative anaerobic gram positive bacterium that resides as normal flora in the oral cavity and gastrointestinal system. This organism has uncommonly presented as an etiology of infective endocarditis, with varying reports of resistance and complications. Methods: Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for the systematic review. A medical librarian (T.R.S) versed in evidence-based medicine systematically searched databases for studies assessing Gemella morbillorum infective endocarditis in patients. Publication year included inception until December 31, 2019. Using Rayyan software, 134 abstracts were screened for eligibility after duplicates were removed. Inclusion criteria was age greater than 18 years old, infective endocarditis with positive culture for Gemella morbillorum, and publication in English. 39 full text articles were reviewed for eligibility, and 38 were included in the final analysis. Results: A total of 40 cases of infective endocarditis caused by Gemella morbillorum were identified. The average age of the patients was 54 years old, 72.5% were male patients (29), 20% female (8), 7.5% unknown sex (3). Native valve endocarditis (NVE) was present in 28 of the cases, with prosthetic valve involvement in 5 cases. Left sided endocarditis was more common than right sided with 70% of cases (28) and 12.5% (5) respectively, with 17.5% (7) of cases not listing which valve was infected on echocardiography. The most common predisposing risk factor was thought to be poor dentition in 9 cases. The most common antibiotic regimen in penicillin susceptible NVE was concordant with most recent guidelines, a beta lactam with gentamicin or vancomycin in 57.5% of the cases (23). Complications occurred in 65% of cases (26), with most common complication being need for surgical intervention occurring in 30% of the cases (12). Conclusions: Gemella morbillorum infective endocarditis cases reported in literature had a high burden of complications with nearly two thirds of cases. Most common was the need for surgery with valve replacement. Antibiotic regimens in the most recent endocarditis guidelines were effective in treatment for a majority of the cases.

Infective endocarditis in patients who use IV drugs: a single centre cohort

Abstract Background Managing endocarditis in intravenous drug use (IVDU) patients is challenging: unless patients successfully quit IVDU, the risk of re-infection is high. Clinicians often raise concerns with ethical and resource allocation principles when considering valve replacement surgery in this patient population. To help inform practice, we sought to determine the long-term outcomes of IVDU patients with endocarditis who underwent valve surgery in our center. Method After research ethics board approval, infective endocarditis cases managed surgically at our General Hospital between 2009 and 2018 were identified through the Cardiac Care Network. We reviewed patients' charts and included those with a history of IVDU in this study. We abstracted data on baseline characteristics, peri-operative course, short- and long-term outcomes. We report results using descriptive statistics. Results We identified 124 IVDU patients with surgically managed endocarditis. Mean age was 37 years (SD 11), 61% were females and 8% had redo surgery. During admission, 45% (n=56) of the patients had an embolic event: 63% pulmonary, 30% cerebral, 18% peripheral and 11% mesenteric. Causative organisms included Methicillin-Sensitive Staphylococcus Aureus (51%, n=63), Methicillin-Resistant Staphylococcus Aureus (15%, n=19), Streptococcus Viridans (2%, n=2), and others (31%, n=38). Emergency cardiac surgery was performed for 42% of patients (n=52). Most patients (84%) had single valve intervention: 53% tricuspid, 18% aortic and 13% mitral. Double valve interventions occurred in 15% (n=18). Overall, bioprosthetic replacement was most commonly chosen (79%, n=98). In-hospital mortality was 7% (n=8). Median length of stay in hospital was 13 days (IQR 8,21) and ICU 2 days (IQR 1,6). Mortality at longest available follow-up was 24% (n=30), with a median follow-up of 129 days (IQR 15,416). Valve reintervention rate was 11% (n=13) and readmission rate was 14% (n=17) at a median of 275 days (IQR 54,502). Conclusion Despite their critical condition, IVDU patients with endocarditis have good intra-hospital outcomes. Challenges occur after hospital discharge with loss of follow-up and high short-term mortality. IVDU relapse likely accounts for some of these issues. In-hospital and community comprehensive addiction management may improve these patients' outcomes beyond the surgical procedure. Annual rate 2009–2018 Funding Acknowledgement Type of funding source: None

Infective endocarditis in patients with solid organ transplantation. A nationwide study

Abstract Background An increase in nosocomial and health care-related infective endocarditis (IE) has been described. Solid organ transplantation (SOT) implies immunosuppression and frequent health care contact. Our aim was to compare characteristics of patients with IE and SOT against those without SOT. Methods We used data from the Spanish Collaboration on Endocarditis obtained during the period 2008–2018. Results We identified 4794 cases of IE, 85 (1.8%) in SOT (56 kidney, 18 liver, 8 heart, 3 lung). Thirteen patients had other types of transplantation (bone marrow, hematopoietic precursors, and cornea) and were excluded from the analysis. Compared with patients without SOT, patients with SOT had a higher median age (69 vs. 61 years, p<0.001), more comorbidities (mean age-adjusted Charlson index 5.7±2.9 vs. 4.9±2.9, p=0.004), a lower prevalence of native valvular heart disease (29.4 vs. 45.4%, p=0.003), more in-hospital and healthcare-related IE (70.5% vs. 36.3%, p<0.001) and Staphylococcus etiology (57.7% vs. 39.7%, p=0.001). Regarding evolution, patients with SOT had more frequent kidney function worsening (47.1% vs. 34.6%, p=0.02), septic shock (25.9% vs. 12.1%, p<0.001), sepsis (27.1% vs. 17.2%, p=0.02). Surgery indication (54.1% vs 66.3%, p=0.02) and surgery (32.9% vs. 46.3%, p=0.01) were less frequent in patients with SOT. We were unable to find significant differences in mortality: inhospital (30.6% vs. 25.6%, p=0.31), 1-year (38.8% vs. 31.9%, p=0.18). Conclusion IE in SOT patients has specific characteristics. Most of the cases are nosocomial and over 70% are hospital-or health care-related. Half have previously normal heart valves and almost 60% are due to Staphylococcus infections. Figure 1. Kaplan Meier survival curves for patients with and without solid organ transplantation (SOT). SOT: 56 kidney, 18 liver (2 combined with kidney), 8 heart, 3 lung. Funding Acknowledgement Type of funding source: None

Post-surgical outcomes in infective endocarditis patients with liver disease: nationwide propensity-match analysis

Abstract Introduction Surgery remains the definitive treatment for persistent infective endocarditis (IE). Age, renal dysfunction and diabetes mellitus are few amongst the many associated with increased post-surgical mortality. Liver dysfunction is a common entity seen in patients with IE. Data on post-surgical sequelae in patients with IE and liver disease is lacking. Method We performed a retrospective cross-sectional analysis of all adult (age>18 years) admissions with a discharge diagnosis of acute or sub-acute IE using the 2016 National Inpatient Sample (NIS). IE patients undergoing valve replacement or repair were identified and divided into two groups based on the presence or absence of liver disease. Propensity score matching was performed to control for confounders such as diabetes, age, smoking among others. Odds of in-hospital mortality, cardiogenic shock, and acute kidney injury were calculated using multivariate logistic regression analysis. IE patients without liver disease undergoing valve surgery were selected as the reference population. Results We identified a total of 9,822 IE related admissions in the 2016 NIS. Amongst all IE admissions, 11.7% (n=1,158) had either valve replacement or repair surgery performed. After using propensity scores for 1 to 1 matching 16.8% of patients (n=195) who had concomitant liver disease were compared with 195 patients without liver disease. In-hospital mortality was significantly higher in patients with hepatic impairment (14.3% vs 0.51%, p=0.004). Patients with liver disease also had higher odds of concurrent cardiogenic shock (OR=9.35, 95% CI=3.01–29.15, p=0.001), acute kidney injury (OR=2.13, 95% CI=1.15–3.93, p=0.01), and thrombocytopenia (OR=2.29, 95% CI=1.13–4.61, p=0.02). Discussion The presence of liver disease in the setting of IE, in patients undergoing valvular surgery significantly increases the morbidity and mortality post-operatively. Functional status of the liver should be considered in addition to the commonly used tools for cardiac operative risk evaluation. Funding Acknowledgement Type of funding source: None

Infective endocarditis after transcatheter or surgical aortic valve implantation: pooled results from three randomized controlled trials

Abstract Background Infective endocarditis is a rare complication of aortic valve replacement with high morbidity and mortality. Data of randomized trials comparing the incidence and outcomes between surgical (SAVR) and transcatheter aortic valve replacement (TAVR) are scarce. Purpose To compare the frequency, timing and outcomes of infective endocarditis after TAVR and SAVR from 3 prospective randomized trials and examine the clinical outcomes. Methods Clinical data from the CoreValve Pivotal High-Risk, the intermediate-risk SURTAVI and the Evolut Low Risk randomized trials, which compared TAVR with a supra-annular, self-expanding transcatheter valve to SAVR, was pooled. Cases of infective endocarditis were independently adjudicated based on Duke's criteria necessitating 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. Baseline clinical and procedural characteristics for patients with and without endocarditis were obtained. The cumulative incidence of endocarditis through 5 years after TAVR or SAVR was determined using death as a competing risk. Kaplan-Meier estimates of all-cause mortality and the composite of all-cause mortality or stroke through 2 years were calculated for both treatment groups. Results Among 2249 TAVR patients, 12 cases of endocarditis (0.5%) were documented and among 1828 SAVR patients, 21 (1.1%) over a mean follow-up time of 2.25±1.58 years. Baseline characteristics were well-balanced between the TAVR and SAVR patients with endocarditis. The cumulative incidence of endocarditis at 5 years was significantly different between the two groups (figure). The prevalence of diabetes was significantly higher in patients with endocarditis than in those without (57.6% vs. 34.2%, p=0.005). In endocarditis patients the rate of all-cause mortality was 39.4% for TAVR patients and 67.8% for SAVR patients at 2 years (log-rank p=0.133). The rates of all-cause mortality or stroke were 55.0% for TAVR and 64.6% for SAVR patients (log-rank p=0.078). Conclusions In this pooled analysis of three randomized trials comparing TAVR with a supra-annular, self-expanding bioprosthesis to SAVR, overall rates of endocarditis were low. The cumulative incidence of infective endocarditis at 5 years was lower in the TAVR group. Mortality after endocarditis was high. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Medtronic

Quadriplegia after Mitral Valve Replacement in an Infective Endocarditis Patient with Cervical Spine Spondylitis

The simultaneous incidence of infective endocarditis and cervical spondylitis with an epidural abscess is rare, and quadriplegia as a complication after cardiac surgery is very rare. We recently observed quadriplegia after mitral valve replacement in an infective endocarditis patient with cervical spine spondylitis. With early symptom detection, immediate examination, and prompt surgical treatment, the patient successfully recovered without neurological symptoms.

Infective Endocarditis: A Growing Concern and Treatment Approaches: An Observational Study

Abstract: Objective: To determine the frequency of prevailing microorganism, treatment approach, different treatment complexities and rationalize the approach for treating Infective Endocarditis (IE) patient. Material and Methods: The retrospective study was conducted from 01st January 2015 to 31st October 2019. Data was collected and after applying exclusion criterion 40 patients were selected and their available record was evaluated. To obtain the conclusive results, frequency and percentages were calculated. Results: The mean age of patient in studied group was 34.02 years with standard deviation (S.D) 13.02 years, and 65% of patients included were male and 35% were female. Staphylococcus aureus (S.aureus) was the prevalent microorganism found in most cases i.e; 60%. Mitral valve was mostly affected; Rheumatic heart disease was the leading factor of IE in patients. Most of the patients complained of shortness of breath and high-grade fever. Benzylpenicillin and aminoglycosides were most commonly prescribed for patients. The medication health care cost was on the higher side at about 1038 PKR/day considering all healthcare facilities provided free by the government. Conclusion: In most of the younger population active infective endocarditis remains the most prevalent disease. Rheumatic heart disease remains to be the most common underlying factor for heart disease. Overall treatment cost of therapy was found to be high due to vigorous antibiotic therapy. Keywords: Infective endocarditis, Microorganism, Rheumatic heart disease, Medication treatment, Vegetation, Staphylococcus aureus

GEMELLA MORBILLORUM: A RARE CAUSE OF INFECTIVE ENDOCARDITIS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Gemella morbillorum is a Gram-positive coccus, catalase negative facultative anaerobe that is normal flora in the oropharynx and gastrointestinal and genitourinary tracts. It is a rare pathogen in infective endocarditis, accounting for <1% of cases. CASE PRESENTATION: A 23 year old male presented to the emergency department complaining of a three day history of nocturnal cough producing bloody, yellow sputum. He denied fever, intravenous drug use, significant past medical history or ill contacts. He had immigrated from Guatemala to Colorado eight months before presentation to work as a painter. In the ED, he developed respiratory failure, presumed a result of pneumonia, and rapidly decompensated into cardiogenic and distributive shock. A transthoracic echocardiogram showed a bicuspid aortic valve and large vegetations on the mitral and aortic leaflets, severe mitral and aortic regurgitation with perforated leaflets, findings consistent with infective endocarditis. Blood cultures were positive with Gram positive cocci in clusters. His tenuous condition required urgent cardiothoracic surgery to replace both mitral and aortic valves. G.morbillorum was identified employing matrix-assisted laser desorption/ionization using time-of-flight mass spectroscopy (MALDI-TOF MS). Consequently, he began intravenous gentamicin and ampicillin. The source of infection was identified on dental panorex as a lucency in his left lateral incisor; on subsequent questioning, the patient disclosed a history of dental carie with filling that fell out and was replaced before arriving in the US. His postoperative course was complicated by recurrent pneumothoraces, complete heart block, atrial fibrillation with rapid ventricular response, and cardiac arrest due to torsades de pointe and ventricular fibrillation ultimately requiring pacemaker/defibrillator implantation prior to discharge. The aforementioned antibiotics were completed over his 31-day hospitalization. DISCUSSION: This case highlights pre-disposing factors associated with endocarditis: male sex, a congenital bicuspid aortic valve, and recent dental work. G. morbillorum is not easily identified with traditional microbiologic methods and requires more sophisticated techniques utilizing mass spectroscopy and advanced PCR. Biofilm production and downregulation of Interleukin-12 / Interferon-γ support this organism’s opportunistic pathogenicity. A recent case series from Cleveland Clinic identified this Gemella species in <1% of endocarditis patients in their registry. CONCLUSIONS: G. morbillorum, although normal flora, may become pathogenic and cause endocarditis in patients with underlying risk factors such as valvular abnormalities, intravenous drug use and prosthetic heart valves. Utilization of advanced identification microbiologic technology facilitates identification and consequent treatment with appropriate antibiotics. Reference #1: A.Ramanathan, S.M.Gordon and N.K.Shrestha, Acaseseries of patients with Gemellaendocarditis, Diagnostic Microbiology&Infectious Disease (2020),https://doi.org/10.1016/j.diagmicrobio.2020.115009 Reference #2: Nagy, E., Becker, S., Kostrzewa, M., Barta Noémi, & Urbán Edit. (2012). The value of MALDI-TOF MS for the identificationof clinically relevant anaerobic bacteria in routinelaboratories. Journal of Medical Microbiology, 61(10), 1393–1400. doi: 10.1099/jmm.0.043927-0 Reference #3: Benedetti, M., Rassu, M., Branscombe, M., Sefton, A., & Giampietro,P. (2009). Gemella morbillorum: an underestimated aetiology of central nervous system infection. Journal of Medical Microbiology. 58, 1652-1656. doi:10.1099/jmm.0.013367-0 DISCLOSURES: No relevant relationships by Geoffrey Blossom, source=Web Response No relevant relationships by Lauren Spaeth, source=Web Response

Vertebral osteomyelitis: Clinical, microbiological and radiological characteristics of 116 patients

Introduction/ObjectivesTo describe the clinical, radiological and microbiological characteristics of vertebral osteomyelitis patients, analysing the factors that played a role on their outcome. Patients and methodsSingle-centre retrospective observational study including patients diagnosed with vertebral osteomyelitis, based on the combination of clinical presentation with either a definitive bacteriological diagnosis and/or imaging studies. Results116 adult patients were included with a mean age of 62.75 (14.98) years. Males predominated (68.10%). Eighteen patients (15.51%) were immunosuppressed. The most frequent symptom was back pain (99.14%) followed by fever, which was detected in 45 patients (38.79%). Puncture-aspiration or biopsy was performed in 84 patients (72.10%) and its culture was positive in 48 samples (57.14%). Gram positive species predominated (73.86%) on cultures, followed by Gram negative (12.5%), mycobacteria (10.23%) and fungi (3.41%). No microorganism was identified in 28 patients (24.14%). On imaging, most of the patients (92.24%) had paravertebral or epidural abscess. 63 cases (54.31%) showed vertebral destruction and 39 (33.62%) cord compression. Twenty-two patients (18.97%) required further surgical procedures and 13 (11.21%) died. ConclusionsThe average patient is middle aged (often male) with a history of subacute back pain, sometimes presenting fever and/or neurological damage on diagnosis. Acute phase reactants are frequently raised. Diabetes mellitus, endocarditis and immunosuppressed patients may have the worst chance of a good outcome, therefore these patients should be more carefully managed (always try to obtain an imaging-guided biopsy, correct antibiotic treatment, and a functional and clinical follow-up).

Retrospective analysis of endocarditis patients to investigate the eligibility for oral antibiotic treatment in routine daily practice.

BackgroundAccording to the current guidelines of the European Society of Cardiology, patients with left-sided infective endocarditis are treated with intravenous antibiotics for 4–6 weeks, leading to extensive hospital stay and high costs. Recently, the Partial Oral Treatment of Endocarditis (POET) trial suggested that partial oral treatment is effective and safe in selected patients. Here, we investigated if such patients are seen in our daily clinical practice.MethodsWe enrolled 119 adult patients diagnosed with left-sided infective endocarditis in a retrospective, observational study. We identified those that would be eligible for switching to partial oral antibiotic treatment as defined in the POET trial (e.g. stable clinical condition without signs of infection). Secondary objectives were to provide insight into the time until each patient was eligible for partial oral treatment, and to determine parameters of longer hospital stay and/or need for extended intravenous antibiotic treatment.ResultsApplying the POET selection criteria, the condition of 38 patients (32%) was stable enough to switch them to partial oral treatment, of which 18 (47.3%), 8 (21.1%), 9 (23.7%) and 3 patients (7.9%) were eligible for switching after 10, 14, 21 days or 28 days of intravenous treatment, respectively.ConclusionOne-third of patients who presented with left-sided endocarditis in routine clinical practice were possible candidates for switching to partial oral treatment. This could have major implications for both the patient’s quality of life and healthcare costs. These results offer an interesting perspective for implementation of such a strategy, which should be accompanied by a prospective cost-effectiveness analysis.Electronic supplementary materialThe online version of this article (10.1007/s12471-020-01490-2) contains supplementary material, which is available to authorized users.

CURRENTLY ADOPTED CONDUCTS IN THE ODONTOLOGICAL CLINIC FOR THE PREVENTION OF BACTERIAL ENDOCARDITIS IN CARDIOPATHIES

Objective: To demonstrate the current drug and behavioral behaviors advocated by the literature in the prevention of bacterial endocarditis in patients at risk in the dental clinic. Study Design: Literature narrative review that consisted of data collection from the Medline and SciELO databases, selecting text in the format of scientific literature review articles and protocols, regarding the use of drugs in the dental clinic for the prevention of bacterial endocarditis in patients at risk. The analysis was done on 6 articles published between 2007 and 2013 by Brazilian students and graduates in dentistry. Results: Bacterial endocarditis is a disease in which infectious agents invade the endocardial surfaces, producing inflammation and damage. Bacteria of the oral microbiota play important roles as etiologic agents of this disease, so its prevention is essential for the dentist. As a preventive measure, antibiotic prophylaxis has generated divergent opinions among scholars regarding its effectiveness. Conclusion: We can understand the relevance of performing antibiotic prophylaxis in at-risk patients before invasive dental procedures, as well as the importance of oral hygiene orientation, since the lack of maintenance of oral health corroborates the occurrence of bacterial endocarditis. Objective: To demonstrate the current drug and behavioral behaviors advocated by the literature in the prevention of bacterial endocarditis in patients at risk in the dental clinic. Study Design: Literature narrative review that consisted of data collection from the Medline and SciELO databases, selecting text in the format of scientific literature review articles and protocols, regarding the use of drugs in the dental clinic for the prevention of bacterial endocarditis in patients at risk. The analysis was done on 6 articles published between 2007 and 2013 by Brazilian students and graduates in dentistry. Results: Bacterial endocarditis is a disease in which infectious agents invade the endocardial surfaces, producing inflammation and damage. Bacteria of the oral microbiota play important roles as etiologic agents of this disease, so its prevention is essential for the dentist. As a preventive measure, antibiotic prophylaxis has generated divergent opinions among scholars regarding its effectiveness. Conclusion: We can understand the relevance of performing antibiotic prophylaxis in at-risk patients before invasive dental procedures, as well as the importance of oral hygiene orientation, since the lack of maintenance of oral health corroborates the occurrence of bacterial endocarditis.

Infective endocarditis in patients after percutaneous pulmonary valve implantation with the stent-mounted bovine jugular vein valve: Clinical experience and evaluation of the modified Duke criteria.

Aims: Percutaneous pulmonary valve implantation (PPVI) has proven good hemodynamic results. As infective endocarditis (IE) remains a potential complication with limited available clinical data, we reviewed our patient records to improve future strategies of IE prevention, diagnosis and treatment.Methods: Medical records of all patients diagnosed with Melody® valve IE according to the modified Duke criteria were retrospectively analyzed in three Belgian tertiary centers.Results: 23 IE episodes in 22 out of 240 patients were identified (incidence 2.4% / patient year) with a clear male predominance (86%). Median age at IE was 17.9 years (range 8.2–45.9 years) and median time from PPVI to IE was 2.4 years (range 0.7–8 years). Streptococcal species caused 10 infections (43%), followed by Staphylococcus aureus (n = 5, 22%). In 13/23 IE episodes a possible entry-point was identified (57%). IE was classified as definite in 15 (65%) and as possible in 8 (35%) cases due to limitations of imaging. Echocardiography visualized vegetations in only 10 patients. PET-CT showed positive FDG signals in 5/7 patients (71%) and intracardiac echocardiography a vegetation in 1/1 patient (100%). Eleven cases (48%) had a hemodynamically relevant pulmonary stenosis at IE presentation. Nine early and 6 late percutaneous or surgical re-interventions were performed. No IE related deaths occurred.Conclusions: IE after Melody® valve PPVI is associated with a relevant need of re-interventions. Communication to patients and physicians about risk factors is essential in prevention. The modified Duke criteria underperformed in diagnosing definite IE, but inclusion of new imaging modalities might improve diagnostic performance.

Analysis of the frequency of bacteraemia of dental origin implicated in infective endocarditis in patients requiring valve surgery

Understanding the frequency of bacteraemia of dental origin that is implicated in severe infective endocarditis (IE) will further our understanding of the disease’s pathoaetiology and help us take steps to reduce its prevalence. A total of 78 patients from the Royal Papworth Hospital, Cambridge, who had valve surgery due to IE (as confirmed by the Modified Duke Criteria) were included. Case notes were retrospectively reviewed for microorganisms that were implicated in the bacteraemia and IE. Associated factors were also recorded to determine whether they were different if a dental or non-dental pathogen was inoculated. A dental pathogen was implicated in 24 of the patients with IE; 20 had non-dental pathogens, and 30 were culture negative. This was not deemed statistically significant (p=0.54). Of the associated factors, only smoking was statistically significant with a greater proportion of non-smokers having bacteraemia of dental origin (p=0.03). No other associated factor was appreciably different based on the aetiology of the microorganism. Our results indicate that dental pathogens are not more likely to cause severe IE. We therefore advocate the stance adopted by the current national guidance on the judicious prescription of antibiotic prophylaxis for IE with regard to dental procedures.

Adult-onset Still's disease accompanying noninfective endocarditis.

Adult-onset Still's disease can develop valve lesions. Since AOSD may complicate valvular lesion, differentiation of endocarditis in patients with AOSD is required.

Clinical characteristics and long-term outcomes of Libman-Sacks endocarditis in patients with systemic lupus erythematosus.

Treatment of Libman-Sacks (LS) endocarditis in patients with systemic lupus erythematosus (SLE) is challenging due to the lack of data. This study aimed to identify the clinical characteristics of SLE patients and LS endocarditis, and to investigate the treatment and prognosis of LS endocarditis. Of all the patients with SLE who underwent echocardiography between 2010 and 2019, 11 and 29 patients with and without LS endocarditis, respectively, were included. We compared the inflammatory and thrombotic profiles between patients with and without LS endocarditis, and investigated the treatment and long-term outcome of LS endocarditis. No significant differences were observed in disease activity, clinical characteristics and inflammatory marker levels between patients with and without LS endocarditis. Patients with LS endocarditis had a significantly higher prevalence of antiphospholipid antibody (aPL) but a lower prevalence of SLE-specific antibody. Triple positivity of aPL was found in 72.7% and 13.8% of patients with and without LS endocarditis, respectively. Of 11 patients with LS endocarditis, six patients received anticoagulation therapy, and five patients received augmented immunosuppressive therapies. One patient who did not receive anticoagulation therapy developed cerebral infarction. Nine (82%) patients with LS endocarditis were classified as having antiphospholipid syndrome (APS). Despite the residual vegetation and valve dysfunction, surgical intervention was not required during the follow-up period of 56.8 months. A significant correlation was observed between APS and LS endocarditis. Anticoagulation therapy should be considered to prevent thromboembolic complications in SLE patients with LS endocarditis.

Epidemiology of infective endocarditis in transcatheter aortic valve replacement: systemic review and meta-analysis.

Infective endocarditis following transcatheter aortic valve replacement (TAVR) is an emerging problem, with a high rate of morbidity and mortality. However, little is known about the burden of disease, and data on infective endocarditis incidence are scarce. This study aimed to evaluate the incidence of infective endocarditis in TAVR by performing a systematic review and meta-analysis of the literature. We comprehensively searched the databases of MEDLINE and EMBASE from inception to October 2019. Included studies were prospective or retrospective cohort studies that reported the event rate of infective endocarditis in patients who underwent TAVR. Data from each study were combined using the random-effects method to calculate pooled incidence with 95% confidence intervals (CIs). A total of 30 studies consisting of 73 780 patients undergoing TAVR were included in this meta-analysis. Overall, the pooled estimated incidence of infective endocarditis following TAVR was 7 in 1000 patients (95% CI: 0.5-1%). For early infective endocarditis, the pooled estimated incidence was 8 per 1000 patients (95% CI: 0.5-1.1%). For late infective endocarditis, the pooled estimated incidence was 2 in 1000 patients (95% CI: 0.1-0.4%). Significantly, the overall pooled infective endocarditis mortality rate was 39% (95% CI: 28.7-49.4%). The current study demonstrates the incidence of overall, early, and late infective endocarditis following TAVR, ranging from 2 to 8 per 1000 patients. Although it remains a rare event, infective endocarditis following TAVR is associated with high mortality.

Bioprosthetic vs mechanical mitral valve replacement for infective endocarditis in patients aged 50 to 69 years

BackgroundThe optimal choice of the valve prosthesis in mitral valve replacement (MVR) for infective endocarditis (IE) is controversial and challenging, particularly for younger patients.HypothesisThe postoperative outcomes of mechanical and biological MVR in IE patients aged 50 to 69 years are different.MethodsAll IE patients aged 50 to 69 years with primary MVR in Hubei province hospitals from 2002 to 2018 were retrospectively reviewed. The median duration of follow‐up was 8.7 years (IQR, 6.8‐10.9 years). Propensity score matching (1:3 ratio) was used to yield 492 patients with comparable baseline features between bioprostheses and mechanical prosthetic valve groups. Outcomes were postoperative mid‐ to long‐ term survival, mitral valve reoperation, prosthetic valve endocarditis (PVE), stroke, and major bleeding events.ResultsFifteen‐year survival after MVR was 80.6% in the mechanical valve group and 69.3% in the bioprostheses group (HR 0.545, P = .040). The cumulative incidence of mitral valve reoperation was 8.8% with mechanical valves and 21.4% with bioprostheses (HR 0.260, P = .002). The cumulative incidence of PVE was 5.6% with mechanical valves and 7.2% with bioprostheses (HR 0.629, P = .435). The cumulative incidence of stroke was 12.9% with mechanical valves and 10.5% with bioprostheses (HR 1.217, P = .647). The cumulative incidence of major bleeding was 12.0% with mechanical valves and 6.75% with bioprostheses (HR 1.579, P = .268).ConclusionsMechanical valve prostheses were associated with better survival, lower rates of reoperation compared with bioprostheses within 15 years after MVR in IE patients aged 50 to 69. These findings suggest mechanical valve prostheses may be a more reasonable alternative to bioprostheses in this patient group.

The diagnostic benefit of 16S rDNA PCR examination of infective endocarditis heart valves: a cohort study of 146 surgical cases confirmed by histopathology

AimsUpon suspicion of infective endocarditis, the causative microorganism must be identified to optimize treatment. Blood cultures and culturing of removed valves are the mainstay of this diagnosis and should be complemented by growth-independent methods. We assessed the diagnostic benefit of examining removed endocarditis valves by broad-range bacterial PCR to detect causative bacteria in cases where culturing was not available, negative, or inconclusive because a skin commensal was detected, in patients from our clinical routine practice.Methods and resultsPatients from Heidelberg University Hospital with suspicion of endocarditis, followed by valve replacement and analysis by 16S rDNA PCR, between 2015 and 2018, were evaluated. 146 patients with definite infective endocarditis, confirmed by the valve macroscopics and/or histology, were included. Valve PCRs were compared to corresponding blood and valve culture results. Overall, valve PCR yielded an additional diagnostic benefit in 34 of 146 cases (23%) and was found to be more sensitive than valve culture. In 19 of 38 patients with both negative blood and valve cultures, valve PCR was the only method rendering a pathogen. In 23 patients with positive blood cultures detecting skin commensals, 4 patients showed discordant valve PCR results, detecting a more plausible pathogen, and in 11 of 23 cases, valve PCR confirmed commensals in blood culture as true pathogens. Only the remaining 8 patients had negative valve PCRs.ConclusionValve PCR was found to be a valuable diagnostic tool in surgical endocarditis cases with negative blood cultures or positive blood cultures of unknown significance.Trial registrationS-440/2017 on 28.08.2017 retrospectively registered.Graphic abstractSubdividing of all infective endocarditis patients in this study, showing that valve PCR yields valuable information for patients with skin commensals in blood cultures, which were either confirmed by the same detection in valve PCR or refuted by the detection of a different and typical pathogen in valve PCR. Additionally, benefit was determined in patients with negative or not available blood cultures and only positive detection in valve PCR. +: Positive; −: negative; n/a: not available results

Predictors of in-hospital mortality in patients with infective endocarditis

Background Infective endocarditis is a serious septic disease, and the epidemiological profile has changed over the last decade. However, there is a paucity of data regarding the current outcome and predictor of in-hospital mortality in patients with infective endocarditis. Methods Consecutive patients diagnosed as infective endocarditis based on the modified Duke criteria at Kansai Medical University hospital from January 2006 to June 2019 were prospectively included. The primary outcome was in-hospital mortality. Cox proportional hazards modelling was used to assess risk factors of in-hospital mortality. Results Of 137 consecutive patients with infective endocarditis (age 60 ± 17 years-old, 62% men, 65% underlying cardiac disease, 11% chronic haemodialysis), 18 (13%) died during hospitalisation. Age and sex were not associated with in-hospital mortality. Patients on chronic haemodialysis exhibited significantly higher in-hospital mortality rate than those without (47 vs. 9%). After adjusting for comorbidities in a multivariate Cox proportional hazards model, chronic haemodialysis was a significant predictor of in-hospital mortality [hazard ratio (HR) 4.22, 95% confidential interval (CI): 1.49–12.0, p < 0.01], independently of C-reactive protein (per 1 mg/dl; HR 1.07, 95%CI: 1.02–1.12, p < 0.05). Conclusions Infective endocarditis in patients on chronic haemodialysis is a serious life-threatening condition that requires early diagnosis and an effective therapeutic approach.

Vertebral osteomyelitis: Clinical, microbiological and radiological characteristics of 116 patients

Introduction/ObjectivesTo describe the clinical, radiological and microbiological characteristics of vertebral osteomyelitis patients, analysing the factors that played a role on their outcome. Patients and methodsSingle-centre retrospective observational study including patients diagnosed with vertebral osteomyelitis, based on the combination of clinical presentation with either a definitive bacteriological diagnosis and/or imaging studies. Results116 adult patients were included with a mean age of 62.75 (14.98) years. Males predominated (68.10%). Eighteen patients (15.51%) were immunosuppressed. The most frequent symptom was back pain (99.14%) followed by fever, which was detected in 45 patients (38.79%). Puncture-aspiration or biopsy was performed in 84 patients (72.10%) and its culture was positive in 48 samples (57.14%). Gram positive species predominated (73.86%) on cultures, followed by Gram negative (12.5%), mycobacteria (10.23%) and fungi (3.41%). No microorganism was identified in 28 patients (24.14%). On imaging, most of the patients (92.24%) had paravertebral or epidural abscess. 63 cases (54.31%) showed vertebral destruction and 39 (33.62%) cord compression. Twenty-two patients (18.97%) required further surgical procedures and 13 (11.21%) died. ConclusionsThe average patient is middle aged (often male) with a history of subacute back pain, sometimes presenting fever and/or neurological damage on diagnosis. Acute phase reactants are frequently raised. Diabetes mellitus, endocarditis and immunosuppressed patients may have the worst chance of a good outcome, therefore these patients should be more carefully managed (always try to obtain an imaging-guided biopsy, correct antibiotic treatment, and a functional and clinical follow-up).