Endocarditis In Patients Research Articles

P4190Incidence of infective endocarditis in patients considered at moderate risk

P4190Incidence of infective endocarditis in patients considered at moderate risk

Correction to: Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association.

Correction to: Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association.

Intravenous Drug Use Is Novel Predictor of Infectious Intracranial Aneurysms in Patients with Infective Endocarditis

Infectious intracranial aneurysms (IIAs) are a rare but potentially devastating complication of infective endocarditis. The clinical and radiographic findings that predispose patients to IIA remain poorly understood. We performed a retrospective review of a prospectively maintained database of consecutive endocarditis patients undergoing catheter-based angiography at a single tertiary-level academic center during the period of July 2013-December 2017. Patient records were reviewed for clinical and radiographic characteristics that may be associated with IIA. Multivariate regression models were used to evaluate the relationship between clinical and radiographic characteristics and presence of IIA on invasive imaging. Of 92 patients included in this analysis, 12 of them with 19 IIAs were discovered. Univariate analysis identified age, male sex, presence of hemorrhage, and history of IV drug use (IVDU) as predictors of IIA presence. After multivariate analysis, only intracranial hemorrhage and IVDU remained as independent predictors of IIA. Presence of hemorrhage on noninvasive imaging and history of IVDU are independently predictive of IIA presence in patients with infectious endocarditis. Risk stratification using these 2 factors may help identify the most vulnerable populations for IIA formation.

Mitral valve repair or replacement in native valve endocarditis? Systematic review and meta-analysis.

The objective of this study is to review the morbidity and mortality associated with mitral valve repair versus replacement in infective endocarditis patients. A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all available data comparing mitral valve repair or replacement in infective endocarditis. Databases were evaluated and assessed to March 2017. Data were analyzed using meta-analytical techniques including odds ratio and mean weighted difference. A total of 8978 patients were analyzed in a total of 14 articles. The average age of the cohort was 53 years. Results revealed a shorter CPB time in the mitral valve (MV) repair compared to replacement group (P = 0.05). Postoperative outcomes (30 days/in hospital events) such as bleeding (P = 0.0047) and recurrence of infective endocarditis (IE) (P = 0.004) were significantly lower in the MV repair group. Beyond 30 days, recurrence of IE was higher in the MV replacement than the repair group (P < 0.0001). Additionally, there were significantly less reoperations in the repair group (P = 0.0021). The MV repair group had significantly better survival at 1 and 5 years postop (P < 0.0001, P < 0.0001). This meta-analysis shows that mitral valve repair has good clinical outcomes both in-hospital and at 1 and 5 years of follow-up. Mitral valve repair should be attempted in those patients in whom sufficient valve tissue is present for reconstruction after all infectious tissue has been resected.

Baseline C-reactive protein levels and prognosis in patients with infective endocarditis: A prospective cohort study

BackgroundEarly diagnosis and risk-stratification among infective endocarditis (IE) patients are limited by poor microbiological yield and inadequate characterization of vegetations. A simple tool that can predict adverse outcomes in the early phase of management is required. AimTo study the prognostic value of C-reactive protein (CRP) levels at admission and its role in predicting various clinical outcomes. MethodsIn a prospective study of consecutive IE patients diagnosed by modified Duke’s criteria, we measured the peak levels of CRP and erythrocyte sedimentation rate (ESR) in the first 3 days of admission and correlated it with in-hospital mortality, six-month mortality, embolic phenomena and the need for urgent surgery. Predefined laboratory-microbiological sampling protocols and antibiotic-initiation protocols were followed. Receiver-operating-characteristics curves were generated to identify a reliable cut-off for CRP in predicting various outcomes. ResultsOut of 101 patients who were treated, 85 patients had ‘definite’ IE. Blood cultures were positive in 55% (n = 39); and Staphylococcus species was the most common organism. Major complications occurred in 74.1% (n = 63) and in-hospital mortality was 32.9% (n = 28). Mean ESR and CRP levels were 102 ± 31 mm/h and 51 ± 20 mg/l, respectively. In multivariable analysis, high CRP levels were independently predictive of mortality, major complications, embolic events and need for urgent surgery. A CRP >40 mg/l predicted adverse outcomes with a sensitivity of 73% and specificity of 99%. ConclusionThe study shows that baseline CRP level in the first 3 days of admission is a strong predictor of short term adverse outcomes in IE patients, and a useful marker for early risk stratification.

Valvectomy Versus Replacement for the Surgical Treatment of Tricuspid Endocarditis

Optimal surgical treatment of infective tricuspid endocarditis is debatable, especially in the setting of inherent social and pathologic concerns. This study compared tricuspid valve repair, replacement, and excision for the treatment of infective endocarditis METHODS: A single-center cardiac surgery database was queried to identify patients aged older than 18 years who underwent tricuspid valve operations for infective endocarditis between 2012 and 2016. Patients were divided into three groups by the type of tricuspid valve operation: valvectomy, repair, or replacement. Patients were evaluated to identify differences between preoperative factors and outcomes, including death, length of stay, and complications. During the study period, 63 patients underwent surgical treatment of infective tricuspid valve endocarditis. Demographic and baseline characteristics were comparable across all groups, except that the valve repair group was older compared with valvectomy and replacement (46 vs 29 and 31 years, respectively; p=0.007), with more hypertension, elevated creatinine, and a lower incidence of diffuse, bilateral pulmonary emboli. Staphylococcus species were the most common organisms. The incidence of death, bleeding requiring reoperation, major stroke, prolonged ventilator time, intensive care unit stay, and overall hospital length of stay were similar in all groups. Of patients undergoing initial valvectomy, 36% were available for follow-up at 1 year, highlighting the challenges associated with the intravenous drug abuse cohort. Patients who underwent tricuspid valvectomy in the group available for follow-up had significantly lower unplanned readmission rates at 1 year. Tricuspid valve endocarditis patients who undergo tricuspid valve excision, repair, and replacement have similar 30-day operative mortality, as defined by The Society of Thoracic Surgeons. Excision patients have significantly lower unplanned readmission rates at 1 year. Tricuspid valvectomy is an acceptable initial treatment in this high-risk group as part of a surgical strategy to identify patients who are candidates for eventual valve replacement. Further study of long-term outcomes and survival is warranted.

Surgery for acute infective endocarditis: epidemiological data from a Spanish nationwide hospital-based registry.

Infective endocarditis (IE) is a serious and eventually lethal disease with rising incidence in the past couple of decades. The aim of this study was to evaluate the contemporary epidemiological trends of surgical endocarditis patients, to analyse the clinical outcomes and to study their profile, associated prognostic factors and costs. This is a retrospective study of all patients admitted for IE in Spanish hospitals and discharged between 1 January 1997 and 31 December 2014. Data were extracted from the minimum basic data set of the National Surveillance System for Hospital Data in Spain provided by the Spanish Ministry of Health. Hospitalizations, comorbidities, outcomes and costs were analysed. In total, 34 399 patients with IE were included; 15.7% of patients received surgical treatment and 84.3% received medical treatment only. Surgical patients were mostly men (71.9%) and had a lower mean age (59.2 ± 16.08 years) than the medical treatment group (P < 0.0001). Mortality among surgical patients showed a decreasing trend between 1997 (32.0%) and 2014 (22.7%) and increased with age (47.6% in ≥85 years of age). Length of hospital stay and the percentage of patients with organ dysfunction were also higher in this group. The cost of the surgical treatment group was higher and increased since 1997 (15 259.22 euros), remaining stable from 2010 (40 700 euros) (P < 0.0001). Surgical treatment in IE has trended upwards in Spain during the last 2 decades. Patients are getting older and more frequently experience organ dysfunction. Mortality ratio steadily declined without changes in the length of hospital stay.

Risk prediction in infective endocarditis by modified MELD-XI score.

The suitability of the model for end-stage liver disease excluding international normalized ratio (MELD-XI) score to predict adverse outcomes in infective endocarditis (IE) patients remains uncertain. This study was performed to explore the prognostic value of the MELD-XI score and modified MELD-XI score for patients with IE. A total of 858 patients with IE were consecutively enrolled and classified into two groups: MELD-XI ≤ 10 (n = 588) and MELD-XI > 10 (n = 270). Multivariate analysis was performed to determine risk factors independent of MELD-XI score. Higher MELD-XI score was associated with higher in-hospital mortality (15.6 vs. 4.8%, p < 0.001) and major adverse clinical events (33.3 vs. 18.4%, p < 0.001). MELD-XI score was an independent predictor of in-hospital death (odds ratio [OR] = 1.06, 95% CI, 1.02-1.10, p = 0.005). Based on a multivariate analysis, NYHA class III or IV (3 points), C-reactive protein > 9.5mg/L (4 points), and non-surgical treatment (6 points) were added to MELD-XI score. Modified MELD-XI score produced higher predictive power than previous (AUC 0.823 vs. 0.701, p < 0.001). The cumulative incidence of long-term mortality (median 29months) was significantly higher in patients with modified MELD-XI score > 13 than those without (log-rank = 25.30, p < 0.001). Modified MELD-XI score was independently associated with long-term mortality (hazard ratio = 1.08, 95% CI, 1.04-1.12, p < 0.001). MELD-XI score could be used as a risk assessment toolin IE. Furthermore, modified MELD-XI score remained simple and more effective in predicting poor prognosis.

Incidence and factors associated with infective endocarditis in patients undergoing left-sided heart valve replacement.

Patients with left-sided heart valve replacement are considered at high-risk of infective endocarditis (IE). However, data on the incidence and risk factors associated with IE are sparse. Through Danish administrative registries, we identified patients who underwent left-sided heart valve replacement from January 1996 to December 2015. Patients were categorized in mitral and aortic valve replacement (MVR and AVR) and followed until: 12 years after valve surgery, end of study, death, emigration, or hospitalization due to IE, whichever came first. Multivariable adjusted Cox proportional hazard analysis was used to investigate which baseline characteristics were associated with IE. A total of 18041 patients were included. The cumulative IE risk at 10 years follow-up was 5.2% in both MVR and AVR patients. In patients with MVR, male sex [hazard ratio (HR) = 1.68, 95% confidence interval (95% CI) 1.06-2.68], bioprosthetic valve (HR = 1.91, 95% CI 1.08-3.37), and heart failure (HR = 1.69, 95% CI 1.06-2.68) were among factors associated with an increased risk of IE. In AVR patients, male sex (HR = 1.59, 95% CI 1.33-1.89), bioprosthetic valve (HR = 1.70, 95% CI 1.35-2.15), and cardiac implantable electronic device (CIED) (HR = 1.57, 95% CI 1.19-2.06) were among factors associated with an increased risk of IE. Infective endocarditis after left-sided heart valve replacement is not uncommon and occurs in about 1/20 over 10 years. Male, bioprosthetic valve, and heart failure were among factors associated with IE in MVR patients while male, bioprosthetic valve, and CIED were among factors associated with IE in AVR patients.

TRENDS IN TRICUSPID VALVE SURGERY SECONDARY TO BACTERIAL ENDOCARDITIS: NATIONAL INPATIENT SAMPLE (NIS) RESULTS

Tricuspid valve endocarditis (TVE) is a complicated medical situation. This study examined trends in patient characteristics and surgical treatment for TVE over time in the US. The sample was comprised of endocarditis patients with TV surgery between 2003-2014 in the National Inpatient Sample (N =

Probiotics and infective endocarditis in patients with hereditary hemorrhagic telangiectasia: a clinical case and a review of the literature

BackgroundIn the last decades, probiotics have been widely used as food supplements because of their putative beneficial health effects. They are generally considered safe but rare reports of serious infections caused by bacteria included in the definition of probiotics raise concerns on their potential pathogenic role in patients with particular predisposing factors. Patients with hereditary hemorrhagic telangiectasia (HHT) are exposed to infections because of telangiectasias and arteriovenous malformations (AVMs). We describe what is, to our knowledge, the first case of infective endocarditis (IE) caused by Lactobacillus rhamnosus in a patient with HHT. A systematic review of the relevant medical literature is presented.Case presentationA patient with HHT and an aortic bioprosthesis was admitted because of prolonged fever not responding to antibiotics. The patient had a history of repeated serious infections with hospitalizations and prolonged use of antibiotics, and used to assume large amounts of different commercial products containing probiotics. Weeks before the onset of symptoms the patient had been treated with nasal packings and with surgical closure of a nasal bleeding site because of recurrent epistaxis. A diagnosis of IE of the aortic bioprosthesis was made. All blood coltures were positive for L. rhamnosus. The patients responded to a cycle of 6 weeks of amoxicillin/clavulanate plus gentamicin. A systematic review of IE linked to consumption of probiotics, and of infective endocarditis in patients with HHT was conducted. 10 cases of IE linked to probiotics consumption and 6 cases of IE in patients with HHT were found.ConclusionsConsumption of probiotics can pose a risk of serious infections in patients with particular predisposing factors. Patients with HHT can be considered at risk because of their predisposition to infections. Prophylaxis with antibiotics before nasal packings in patients with HHT can be considered.

Infective endocarditis in patients with oncological diseases

IntroductionCancer patients may constitute a special risk group for the development of infective endocarditis (IE) because they are often subjected to invasive procedures. The aim of this study is to determine the differential clinical profile and prognosis of patients with IE and cancer. MethodsA retrospective observational study was conducted on all patients consecutively diagnosed with IE in a single centre between 2005 and 2015. A comparative analysis was performed between patients with cancer and those free of disease, as well as a long-term follow-up. ResultsThere were 208 IE cases, of which 32 had a cancer diagnosis. There were no significant differences in age (67.5 [59.2–74] vs 64 [51–74] years). The Charlson comorbidity index was same whether cancer was diagnosed or not (4 [2.2–5] vs 3.9 [2–5]). IE in cancer patients was mainly associated with health care (59.5% vs 24.4%, p<0.001). Staphylococcus aureus was the main causative agent (35%), and the tricuspid location was three times more common (18.8% vs 6.2%). Surgery was not performed in 18.7% of patients, despite having an indication, compared with 7.4% of patients without cancer. In-hospital mortality for cancer patients was 45.5%, and the probability of survival at one year was 40%. ConclusionsIE in patients with cancer is predominantly caused by staphylococci, and has high early mortality. Although it is often related to health care, patients are limited from the therapeutic point of view.

Surgical outcomes of mitral valve replacement with concomitant mitral annular reconstruction.

We evaluated the early and long-term outcomes of mitral annular reconstruction (MAR) with pericardium during mitral valve replacement (MVR), and analyzed the risk factors associated with post-operative mortality. Between May 1997 and April 2013, 78 consecutive patients underwent MVR with MAR. The indications for MAR were treatment for annular infection in native valve endocarditis (n = 23, 29.5%) or prosthetic valve endocarditis (n = 26, 33.3%), reinforcement of damaged annulus resulting from a previous operation (n = 17, 21.8%), complete excision of extensive calcification (n = 9, 11.5%), and left ventricular or left atrial rupture (n = 3, 3.8%). Patients were classified into infective endocarditis (n = 49) and non-endocarditis groups (n = 29). The mean follow-up period was 59.4 ± 47.3 months. There were two operative deaths and 11 cases of late mortality in the endocarditis group and five cases in the non-endocarditis group. Late prosthetic valve endocarditis occurred in four patients. The overall survival rate at 1 and 10 years was 94.8% and 65.1%, respectively. There was no statistical difference in the overall survival, freedom from reoperation, and freedom from endocarditis rates between the groups (P = 0.565, P = 0.635, and P = 0.449, respectively). Univariable and multivariable analyses revealed that pre-operative left ventricular dysfunction (ejection fraction <40%) was an independent predictor of overall mortality. The early and long-term results of MAR with pericardium during MVR are acceptable in both endocarditis and non-endocarditis patients.

Altering lipid droplet homeostasis affects Coxiella burnetii intracellular growth

Coxiella burnetii is an obligate intracellular bacterial pathogen and a causative agent of culture-negative endocarditis. While C. burnetii initially infects alveolar macrophages, it has also been found in lipid droplet (LD)-containing foamy macrophages in the cardiac valves of endocarditis patients. In addition, transcriptional studies of C. burnetii-infected macrophages reported differential regulation of the LD coat protein-encoding gene perilipin 2 (plin-2). To further investigate the relationship between LDs and C. burnetii, we compared LD numbers using fluorescence microscopy in mock-infected and C. burnetii-infected alveolar macrophages. On average, C. burnetii-infected macrophages contained twice as many LDs as mock-infected macrophages. LD numbers increased as early as 24 hours post-infection, an effect reversed by blocking C. burnetii protein synthesis. The observed LD accumulation was dependent on the C. burnetii Type 4B Secretion System (T4BSS), a major virulence factor that manipulates host cellular processes by secreting bacterial effector proteins into the host cell cytoplasm. To determine the importance of LDs during C. burnetii infection, we manipulated LD homeostasis and assessed C. burnetii intracellular growth. Surprisingly, blocking LD formation with the pharmacological inhibitors triacsin C or T863, or knocking out acyl-CoA transferase-1 (acat-1) in alveolar macrophages, increased C. burnetii growth at least 2-fold. Conversely, preventing LD lipolysis by inhibiting adipose triglyceride lipase (ATGL) with atglistatin almost completely blocked bacterial growth, suggesting LD breakdown is essential for C. burnetii. Together these data suggest that maintenance of LD homeostasis, possibly via the C. burnetii T4BSS, is critical for bacterial growth.

Biofilm formation and transcriptome analysis of Streptococcus gallolyticus subsp. gallolyticus in response to lysozyme.

Streptococcus gallolyticus subsp. gallolyticus is a commensal bacterium of the human gastrointestinal tract, and a pathogen causing infective endocarditis and other biofilm-associated infections via exposed collagen. This study focuses on the characterization of the biofilm formation and collagen adhesion of S. gallolyticus subsp. gallolyticus under different conditions. In this study, it has been observed that the isolate UCN 34 is resistant to 20 mg/ml lysozyme in BHI medium, whereas the strain BAA-2069 builds more biofilm in the presence of lysozyme compared to in a control of BHI without lysozyme. A transcriptome analysis with whole genome microarrays of these two isolates in BHI medium with lysozyme compared to control without lysozyme revealed changes in gene expression levels. In the isolate BAA-2069, 67 genes showed increased expression in the presence of lysozyme, while in the isolate UCN 34, 165 genes showed increased expression and 30 genes showed decreased expression through lysozyme treatment. Products of genes which were higher expressed are in involved in transcription and translation, in cell-wall modification, in hydrogen peroxide resistance and in bacterial immunity. Furthermore, the adhesion ability of different strains of S. gallolyticus subsp. gallolyticus to collagen type I and IV was analyzed. Thereby, we compared the adhesion of 46 human isolates with 23 isolates from animals. It was shown that the adhesion ability depends significantly on whether the isolate was isolated from human or animal. For example, high adhesion ability was observed for strain UCN 34 isolated from an infective endocarditis patient, whereas strain DSM 16831 isolated from koala feces adhered only marginally to collagen. Full genome microarray analysis of these two strains revealed strain-dependent gene expression due to adhesion. The expression of 25 genes of a transposon and 15 genes of a phage region in strain DSM 16831 were increased, which corresponds to horizontal gene transfer. Adherence to collagen in strain UCN 34 led to higher expression of 27 genes and lower expression of 31 genes. This was suggestive of a change in nutrient uptake.

Abstract WP325: Peri-operative Neurological Complications of Valve Surgery for Infective Endocarditis Patients With Stroke

Introduction: Surgical valve repair is often delayed for infective endocarditis (IE) patients with stroke. We compared neurological outcome of early and delayed valve surgery and identified pre-surgical imaging characteristics that were associated with perioperative neurological complications. Methods: We reviewed 228 patients with acute IE diagnosed by modified Duke’s Criteria who underwent cerebral angiogram (CA) between January 2010 - December 2016 at a single center. Patients without pre-surgical CT and MRI were excluded. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis, delayed as &gt;14 days. Peri-operative neurological complication is any new clinical or radiologic diagnosis of ischemic or hemorrhagic stroke, and seizure. Results: 148 of 228 patients underwent valve surgery. 69 patients (46.6%) had early surgery at median 9 days after IE diagnosis, and 79 patients (53.4%) had delayed surgery at median 28 days. On pre-surgical imaging, acute to subacute ischemic stroke was seen in 81% of the early group (n=56) and 78% of the delayed group (n=62, p=0.69). However, 22.8% of patients (n=18) in the delayed group had evidence of subarachnoid hemorrhage (SAH) compared to 10.1 % of patients in the early group (n=7, p=0.04). Despite this finding, delayed group did not have higher rate of perioperative neurological complication than that of the early group (24.1% vs 13%, p=0.95). Overall, 15 surgical patients (10.1%) had perioperative neurological complications: 4 with acute ischemic stroke, 9 with ICH, 1 with both an infarct and ICH, and 3 with seizures. 33.3% of patients who had a perioperative neurological complication had evidence of SAH on pre-surgical imaging (n=6) compared to 14.6% of patients who did not have any neurological complications (n=19, p=0.012). In the group of patients with complications, SAH found prior to surgery were all cortical in the sulci, and 3 cases of SAH were associated with presence of infectious intracranial aneurysm found on pre-surgical CA. Conclusion: In IE patients with stroke, presence of sulcal SAH on pre-surgical imaging is associated with developing perioperative neurological complications irrespective of surgical timing.

Schistosoma mansoni and endocarditis: from egg to free DNA detection in Egyptian patients and infected BALB/c mice.

With the growing incidence of closed schistosomiasis and uncommon presentations, there is a risk of the infection rate being underestimated. A study in Japan reported an unexplained case of endocarditis that was finally diagnosed as a complex Schistosoma japonicum infection; in the absence of advanced techniques, the diagnosis was delayed. We therefore set out to explore the incidence of Schistosoma mansoni in endocarditis patients coming from areas of Egypt where S. mansoni is endemic. We also investigated histopathological changes in the cardiac valves and the presence of cell-free parasite DNA (CFPD) in cardiac tissues of laboratory mice infected with S. mansoni. The study included 186 patients with the manifestations of infective endocarditis. Eggs were detected in the stool samples of 5.91% of patients. Seropositivity was reported in 23.66% of patients and antigen was detected in the urine samples of 10.21%. Using real-time polymerase chain reaction (PCR), CFPD was detected in the blood of 6.98% of the endocarditis patients and 95% of the infected mice, while the cardiac samples of 45% of the mice tested positive for CFPD (means ± SD = 1390.2 ± 283.65, 2158.72 ± 1103.1 and 5.71 ± 2.91, respectively). Histopathological examination revealed abnormal collagen deposition, inflammatory cells and haemorrhagic pigmentation in the heart sections. Despite the low incidence of S. mansoni infection in the studied cohort, the presence of CFPD in the cardiac tissue of infected mice makes it necessary to: (1) investigate the hazards of CFPD deposition in endothelium-rich organs; and (2) test the potential of CFPD to trigger tissue inflammation, abnormal proliferation or genome integration.

Implications of Antimicrobial Usage to Prevent Bacteremia for Periodontal Therapy

This review examines the current literature on periodontal treatment, bacteremia and prophylactic antibiotic usage to prevent the systemic adverse outcomes. Currently, it is not clear whether prophylactic antibiotic administration prevents bacterial endocarditis in patients with high risk. Recent publications have resulted in significant changes in the concept of antibiotic prophylaxis. Available evidence does not support the previously published guidelines recommending prophylactic antibiotic usage prior to dental treatment. Potential harms and costs of antibiotic administration should be weighed against expected benefits. Clinicians are advised to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before prescription.

Effect of cerebral embolus size on the timing of cardiac surgery for infective endocarditis in patients with neurological complications.

The optimal timing of cardiac surgery remains unclear for patients with neurological complications of infective endocarditis (IE). However, neuroimaging findings may allow more refined clinical decision-making. We analyzed clinical and advanced neuroimaging data for 135 patients with IE who had preoperatively diagnosed ischemic cerebral complications (86 patients) or hemorrhagic complications (49 patients), between January 1997 and May 2013. The effect of early surgery (within 3 and 7days of ischemic and hemorrhagic complications respectively) on in-hospital mortality and 1-year adverse outcomes (mortality, relapse, or new embolic events) was estimated. Small cerebral emboli (≤2cm) led to early surgery (cases with ischemic complications: 57% vs 26%, p = 0.04; cases with hemorrhagic complications: 56% vs 13%, p = 0.02). Early surgery was not significantly associated with increased rates of in-hospital mortality and 1-year adverse outcomes among patients with ischemic complications (14% vs 9%, odds ratio [OR] 1.67, 95% confidence interval [CI] 0.44-6.38, p = 0.52; 17% vs 14%, OR 1.27, 95% CI 0.39-4.14, p = 0.7 respectively). Only 1 patient (4%) with hemorrhagic complications experienced in-hospital mortality in the early surgery group, and early surgery was not significantly associated with 1-year adverse outcomes (21% vs 12%, OR 1.93, 95% CI 0.41-9.16, p = 0.46). The risks of in-hospital mortality and 1-year adverse outcome were not increased, even if cardiac surgery had been carried out earlier than previously described. Our findings suggest that early surgery, when indicated, may be performed for patients with IE and neurological complications, especially if the cerebral embolus has a diameter of ≤2cm.

A rationale for combination ampicillin and daptomycin in renal transplant patients with enterococcal infective endocarditis.

Treatment of enterococcal endocarditis in patients with history of renal transplantation is complicated. Treatment failure and/or drug toxicities are not uncommon. Treatment with ampicillin and daptomycin in a renal transplant patient has been rarely reported. Here we report a patient who was successfully treated with this novel combination.