Episodes Of Infective Endocarditis Research Articles

P1418 Clinical profile and outcome of infective endocarditis patients transferred to a tertiary center

Abstract Previous studies have described a selection bias with more need for surgery in patients transferred to a tertiary referral hospital. In addition, multidisciplinary Infective Endocarditis units establish criteria for referring patients to the tertiary hospital and keep in contact with the county hospital. METHODS Prospective observational study with a retrospective analysis of 468 episodes of infectious endocarditis admitted to our center from 2003 to 2018. Of these, 252 (54%) were admitted directly in our center and 216 (46%) were transferred from hospitals in the area of influence. We analyze the features and compare them. RESULTS The average age from transferred patients was lower (63 vs. 66 years; p = 0.015), from which 74% were men. Non-transferred patients had major comorbidity with a significant percentage of comorbidities (81 vs. 66%; p = 0.005), greater Charlson"s index (3.4 vs. 1.98; p 0.005) and EuroScore (logistic Euroscore I ; 27 vs. 22; 0.034). The diagnosis delay was similar (7.3 vs. 7.6 days) with a large number of clinical (84% vs. 73%) and echocardiographic (52 vs. 40; p = 0,012) complications in transferred patients with more need for surgery (81 vs. 61%, p = 0.002), and with more operated patients of those transferred. The mortality of non-transferred patients, admitted directly in the tertiary center, was higher (51 vs. 43%), but presenting no significant differences. CONCLUSIONS Patients transferred from other centers have a profile with less comorbidity but high need for surgery, possibly related to well-stablished selection and derivation criteria, with a slightly lower mortality, although with no significant differences in comparison to patients admitted directly to the tertiary referral hospital.

170. Predictors of Recurrent Infective Endocarditis in Intravenous Drug Users

BackgroundCaring for hospitalized patients with infective endocarditis (IE) can be challenging due to the nature of the disease and its complications, underlying medical and psychiatric problems, socioeconomic status and environmental factors.Some of these patients develop recurrent IE after the first episode treated. On-going intravenous (IV) drug use after hospital discharge is the highest predictive factor for recurrent IE. Besides IV drug use, there are limited data of other contributing factors to recurrent IE. Those factors may be modifiable during the first hospitalization to reduce the incidence of recurrent IE.MethodsA retrospective cohort study was conducted at a large tertiary acute care medical center in Tampa, Florida. All consecutive patients with IE with history of IV drug use from January, 2011 to December, 2017 were included. Basic demographic information, co-morbidities (diabetes, hypertension, chronic lung and kidney diseases, HIV, Hepatitis B and C status, coronary artery diseases), valves involved, length of stay, complications at their first IE episode such as septic shock and stroke were included. Groups were identified based on the first episode, first recurrence and second or more recurrences of IE.ResultsA total of 106 patients were identified based on the inclusion criteria. The association between the type of valve infection (right side and left side) and IE recurrence was found to be statistically significant. (P = 0.003). Right side valves are prone to have recurrent IE episodes. People with recurrent IE were more likely to have septic shock (P = 0.02) and requiring intensive care unit (ICU) admissions (P < 0.001) during their first episode There was no statistically significant difference between other demographic information and recurrent endocarditis as well as other parameters such as organisms or type of substance used. (Table 1)ConclusionRight-sided IE and presence of septic shock during their first episode of IE may be the predictors for recurrent IE. Interventions including closer follow-up, more aggressive septic shock recognition and management, socioeconomic assessment in addition to substance abuse treatments after discharge should be considered to prevent recurrent IE. Disclosures All authors: No reported disclosures.

193. Comparison of Survival for MSSA and MRSA Endocarditis

BackgroundPrior studies have yielded conflicting findings regarding outcomes for MRSA vs. MSSA infective endocarditis (IE). Our experience suggests that MSSA IE is not any less severe than MRSA IE. The purpose of this study was to compare survival in MSSA and MRSA IE.MethodsEpisodes of IE caused by Staphylococcus aureus were identified from the Cleveland Clinic Infective Endocarditis Registry. Only the first episode was included for each patient. Acceptance for surgery was considered surgical treatment. Survival from the surgical decision date was compared for MSSA vs. MRSA endocarditis using multivariable Cox proportional hazards regression. Selection of variables for the model was done by stepwise backward elimination from a collection of clinically important baseline variables.ResultsBetween January 1, 2008 and January 1, 2010, 76 episodes of IE caused by S. aureus were identified. The mean (SD) patient age was 58 (15) years, 46 (61%) were males, 14 (18%) had a prior history of IE, 33 (43%) had diabetes mellitus, 22 (29%) had end-stage renal disease (ESRD), 27 (36%) had prosthetic valve endocarditis (PVE), 70 (92%) had left side involvement, 27 (36%) had invasive disease, 59 (78%) were referred patients, and 39 (51%) were treated surgically. The mean (SD) time to decision on surgery was 6 (7) days. Of these episodes 40 (53%) had MSSA IE and 36 (47%) had MRSA IE. There was no difference in hazard of death between MSSA and MRSA IE (HR 0.98, 95% C.I. 0.54–1.78, P-value 0.96), after adjusting for age, ESRD, prior history of IE, PVE, invasive disease, calendar year, and surgical treatment, which were the significant explanatory variables in the multivariable analysis. Survivals predicted by the model for a reference patient with MSSA IE and MRSA IE are shown in the figure.ConclusionPreliminary findings suggest that survival in MSSA IE may be similar to that in MRSA IE. The study is limited by its small sample size. The study finding will need confirmation with a larger sample. Disclosures All authors: No reported disclosures.

197. Infective Endocarditis Over a Five-Year Period in an Academic Teaching Center: The Validity of ICD Codes vs. Manual Chart Review

BackgroundOpioid dependence and overdose are at epidemic levels in the United States. Ohio has the third highest rate of opioid-related overdose deaths. Infectious complications of intravenous drug use (IDU) include increased acquisition of hepatitis C, HIV and infective endocarditis. In this study, we aimed to characterize cases of infective endocarditis admitted to our healthcare system over a five-year period. We additionally sought to determine the validity of using ICD codes to identify infective endocarditis cases and IDU.MethodsPatients with ICD-9 or 10 discharge diagnosis codes for infective endocarditis were identified from our institution’s electronic health record. ICD codes pertaining to substance abuse were used to classify patients according to IDU status. Readmissions during the same episode of infective endocarditis were excluded. We compared chart review to ICD code for the identification of infective endocarditis and IDU in a random sample of 296 of 1590 cases.ResultsOf 296 charts reviewed, 133 (44.9%) were excluded because they did not meet criteria for definite infective endocarditis by modified Duke’s criteria or because the episode was a readmission. A total of 163 (55.1%) cases met inclusion criteria, all of whom were seen in consultation by the inpatient Infectious Disease service. Of these, 52 (31.9%) had ICD 9 or 10 codes linked to substance abuse. Following manual chart review, we established that in fact 86 of these 163 cases (52.8%) had evidence of substance abuse.ConclusionMisclassification due to use of ICD codes is a well-established challenge to epidemiological research. However, the extent of misclassification in this analysis was greater than expected. If prior research on IDU and infective endocarditis has relied on medical record data alone without verification through manual chart review, the observed epidemiological trends may not be accurate.Disclosures All authors: No reported disclosures.

198. Chart Validation of an Algorithm for Identifying Patients with Intravenous Drug Use-Associated Endocarditis Using Administrative Code Data

BackgroundStudies using administrative data have described increasing rates of intravenous drug use (IVDU)-associated infective endocarditis (IE) in the United States. These studies used International Classification of Disease (ICD) diagnosis codes to identify hospitalized patients with IE and any illicit drug use (i.e., opioid, amphetamine, cocaine or sedative), but were hindered by absence of specific ICD codes for IVDU. We reviewed charts to determine the positive predictive value (PPV) of ICD codes for identifying patients with IE and IVDU.MethodsWe examined national Veterans Affairs (VA) administrative data from January 2010 to December 2017 to identify patients hospitalized for a first episode of potential IVDU-associated IE based on inpatient ICD 9 and 10 codes for both IE and any illicit drug use, the algorithm used to identify IVDU-IE in most prior studies. We randomly selected 100 of these patients nationally and reviewed hospital charts to confirm clinical documentation of: (1) IE, (2) any illicit drug use, and (3) current or past IVDU.ResultsWe identified 340 patients with concurrent ICD codes for IE and drug use, increasing from 28 in 2010 to 51 in 2017 (82% increase). In chart review of 100 randomly selected patients, the PPV of ICD codes was 93% (95% CI 88–98%) for a documented clinical diagnosis of IE; 96% (95% CI 92–100%) for documented drug use by any route; and 63% (95% CI 53–73%) for documented IVDU. Among the 37% of patients without clinically documented IVDU, 30% (i.e.,11% of total patients) had clinical documentation stating that drug use was only by non-IV routes, 59% (22% of total) had documented drug use without mention of route of use, and 11% (4% of total) had clinical documentation that patients denied any drug use.ConclusionThe incidence of first hospitalization for IE among patients with ICD codes for drug use increased by 82% from 2010 to 2017 in VA care. Concurrent ICD codes for illicit drug use had moderate PPV for identifying IVDU in setting of IE, largely due to identification of patients using drugs without documented intravenous use. There is a need to develop more accurate case-finding algorithms for identifying patients with IVDU-associated endocarditis, for both epidemiologic surveillance and quality improvement applications.Disclosures All authors: No reported disclosures.

Contemporary epidemiology and outcomes in recurrent infective endocarditis

ObjectiveRecurrent infective endocarditis (IE) is a major complication of patients surviving a first episode of IE. This study sought to analyse the current state of recurrent IE in a large...

P1802Management and outcomes of infective endocarditis in adults with congenital heart disease

Abstract Background Causes, epidemiology and microbiology of infective endocarditis (IE) have evolved in recent decades. Although novel tools for the diagnosis and therapeutic strategies have emerged, mortality and morbidity remain high. These trends may particularly concern the growing population of adults with congenital heart disease (CHD) who are at increased risk for IE. Purpose We aimed to characterize IE in CHD patients and describe management and outcome in this setting. We also sought to determine the risk factors associated with in-hospital death in CHD patients. Methods From January 2000 to June 2018, 666 consecutive episodes of IE in adults were recorded in our center. Among them, 143 concerned CHD, including 5 implantable cardiac electronic devices-lead infections, all managed by an IE team including CHD specialists. Cases were classified according to modified Duke criteria. Results CHD patients were significantly younger (37 years IQR [26–52]), with a more common history of cardiac reoperations (numbers of sternotomies≥2 in 35.7%) and infective endocarditis (19.7%, p&lt;0.01) compared to non-CHD patients. There were more infections of valve-containing prosthetics (44% vs. 30%, p&lt;0.04), and the right heart side (41.5%, p&lt;0.01) in CHD patients. Forty-nine percent of them had a simple CHD, 12.7% a moderate, and 36.4% a complex. A predisposing event could be identified in only 34% of cases. Oral streptococci/Streptococci bovis and Staphylococcus aureus were the most frequently microorganisms isolated (32.4% and 20.4%, respectively). Surgery was performed in 90 episodes (62%), and was selected in emergency (&lt;24h) in 61% (figure 1). In-hospital mortality was 12.7% and was directly related to IE in 10/18 cases. CHD patients had a significant lower risk of death compared to non-CHD patients (OR=0.47, p=0.026, p&lt;0.01), even after adjustment for age, and the infected heart side. On multivariate analysis the complexity of CHD (if simple CHD: OR=0.07 IQR [0.01 to 0.44], p&lt;0.01) and the white blood cell count (OR=1.18 IQR [1.04 to 1.33], p=0.01) were the strongest predictive factors of in-hospital death in the CHD group. Conclusions Mortality associated with IE in CHD patients is lower than in acquired heart disease. The multidisciplinary approach by IE team and CHD specialists may have improved management and outcome in this setting. However, risk for death remains high in complex lesions. Larger prospective studies on IE in adults with CHD are needed to develop guidelines in these complex patients.

Virulence of beta-hemolytic streptococci in infective endocarditis.

Streptococci involved in infective endocarditis (IE) primarily comprise alpha- or non-hemolytic streptococci (ANHS). Moreover, beta-hemolytic streptococci (BHS) can be involved, and guidelines recommend the addition of gentamicin for the first 2weeks of treatment and the consideration of early surgery in such cases. This study compared the morbidity and mortality associated with IE depending on the microorganisms involved (BHS, ANHS, staphylococci, and enterococci). We conducted a retrospective observational study between 2012 and 2017 in a single hospital in France. The endpoints were overall in-hospital mortality, 1-year mortality and the occurrence of complications. We analyzed 316 episodes of definite IE including 150 (38%), 96 (25%), 46 (12%), and 24 cases (6%) of staphylococcal, ANHS, enterococcal, and BHS IE, respectively. In-hospital mortality was significantly higher in the staphylococcal (n = 40; 26.7%) and BHS groups (n = 6; 25.0%) than in the ANHS (n = 9; 9.4%) and enterococcal groups (n = 5; 10.9%) (all p < 0.01). The rates of septic shock and cerebral emboli were also higher in the BHS group than in the ANHS group [n = 7 (29.2%) vs. n = 3 (3.1%), p < 0.001; n = 7 (29.2%) vs. n = 12 (12.5%); p = 0.05, respectively]. This study confirmed that BHS IE has a more severe prognosis than ANHS IE. The virulence of BHS may be similar to that of staphylococci, justifying increased monitoring of these patients and more 'aggressive' treatments such as early surgery.

From contamination to infective endocarditis\u2014a population-based retrospective study of Corynebacterium isolated from blood cultures

Corynebacterium is a genus that can contaminate blood cultures and also cause severe infections like infective endocarditis (IE). Our purpose was to investigate microbiological and clinical features associated with contamination and true infection. A retrospective population-based study of Corynebacterium bacteremia 2012–2017 in southern Sweden was performed. Corynebacterium isolates were species determined using a matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI-TOF MS). Patient were, from the medical records, classified as having true infection or contamination caused by Corynebacterium through a scheme considering both bacteriological and clinical features and the groups were compared. Three hundred thirty-nine episodes of bacteremia with Corynebacterium were identified in 335 patients of which 30 (8.8%) episodes were classified as true infection. Thirteen patients with true bacteremia had only one positive blood culture. Infections were typically community acquired and affected mostly older males with comorbidities. The focus of infection was most often unknown, and in-hospital mortality was around 10% in both the groups with true infection and contamination. Corynebacterium jeikeium and Corynebacterium striatum were significantly overrepresented in the group with true infection, whereas Corynebacterium afermentans was significantly more common in the contamination group. Eight episodes of IE were identified, all of which in patients with heart valve prosthesis. Six of the IE cases affected the aortic valve and six of seven patients were male. The species of Corynebacterium in blood cultures can help to determine if a finding represent true infection or contamination. The finding of a single blood culture with Corynebacterium does not exclude true infection such as IE.

Long-term Outcomes Are Poor in Intravenous Drug Users Following Infective Endocarditis, Even After Surgery.

Previous studies of outcomes in people who inject drugs (PWID) with infective endocarditis (IE) have often been retrospective, have had small sample sizes, and the duration of follow-up has been short and limited to patients who were operated on. PWID treated for IE between 1 January 2006 and 31 December 2016 were identified from a prospectively collected database. PWID hospitalized with other infections acted as a novel comparison group. Outcomes were all-cause mortality, cause of death, relapse, recurrence, and reoperation. There were 105 episodes of IE in 92 PWID and 112 episodes of other infections in 107 PWID in whom IE was suspected but rejected. Survival at 30 days for the IE group was 85%, and 30-day survival following surgery was 96%. The most common pathogens were Staphylococcus species (60%) and Streptococcus species (30%). The surgical intervention rate was 47%. Survival for the IE group at 1, 3, 5, and 10 years was 74%, 63%, 58%, and 44%, respectively. This was significantly lower compared with the comparator group of other infections in PWID (P = .0002). Mortality was higher in patients who required surgery compared with those who did not (hazard ratio, 1.8 [95% confidence interval, .95-3.3]). The commonest cause of death was infection (66%), usually a further episode of IE (55%). Although early survival was good, long-term life expectancy was low. This was attributable to ongoing infection risk, rather than other factors known to affect prognosis in PWID. Surgery conferred no long-term survival advantage. More efforts are needed to reduce reinfection risk following an episode of IE in PWID.While early survival for people who inject drugs (PWID) with infective endocarditis is good, long-term survival is poor due to ongoing infection risk. Surgery conferred no long-term survival advantage, so more efforts are needed to reduce reinfection risks for PWID.

Contemporary epidemiology of infective endocarditis in patients with congenital heart disease: A UK prospective study

Infective endocarditis is a life-threatening complication of congenital heart disease (CHD), but there are few studies concerning the contemporary risk profile, preceding invasive procedures and outcomes in this patient population. The aim of this study was to investigate the epidemiology of infective endocarditis (IE) in patients with CHD. Cases of IE in children and adults with CHD were prospectively recorded as part of the UK National Institute for Cardiovascular Outcomes Research (NICOR) National Congenital Heart Disease Audit. Patients were entered into the database between April 2008 and March 2016. Eight hundred episodes of IE were recorded in 736 patients with CHD. Sixty-five patients (9%) were infants (aged <1 year), 235 (32%) were children (aged 1-15 years), and 436 (59%) were adults (aged >15 years). The most common diagnoses were Tetralogy of Fallot (n = 150, 22.8%), ventricular septal defect (n = 129, 19.6%) and bicuspid aortic valve (n = 70, 10.7%). Dental procedures preceded 67 of 635 episodes (11%) of IE, and non-dental invasive procedures preceded 177 of 644 episodes (27.4%). The most common causative organisms were streptococci, accounting for 40% of cases. Overall in-hospital mortality was 6.7%. On multivariable analysis, adverse factors associated with in-hospital mortality were staphylococcal infection and presence of an underlying atrioventricular septal defect. Infective endocarditis in patients with CHD is an ongoing clinical challenge. In contemporary practice in tertiary congenital centers, 1 of 15 patients do not survive to hospital discharge. Streptococci remain the most common causative organism, and antecedent dental or medical procedures were undertaken in a significant minority in the 3 months before diagnosis. The presence of an atrioventricular septal defect or staphylococcal infection is associated with significantly increased risk of early mortality.

Acute kidney injury in infective endocarditis: A retrospective analysis

BackgroundAcute kidney injury (AKI) is associated with high case fatality in infective endocarditis (IE), but epidemiological data on the frequency of AKI during IE is scarce. We aimed to describe the frequency and risk factors for AKI during the course of IE using Kidney Disease: Improving Global Outcomes consensual criteria. MethodsUsing the French hospital discharge database (French acronym PMSI), we retrospectively reviewed the charts of 112 patients presenting with a first episode of probable or definite IE between January 2010 and May 2015. ResultsSeventy-seven patients (68.8%) developed AKI. In univariate analysis, risk factors for AKI were cardiac surgery for IE (n=29, 37.7% vs. n=4, 1.4%, P<0.0005), cardiac failure (n=29, 36.7% vs. n=1, 2.9%, P<0.0005), diabetes mellitus (n=14, 18.2% vs. n=1, 0.9%, P=0.034), and prosthetic valve IEs (n=24, 31.2% vs. n=4, 11.4%). No differences were observed for gentamicin exposure (n=57, 64% vs. n=32, 86.5%, P=0.286). Prosthetic valve IE, cardiac failure, and vancomycin exposure were independently associated with AKI with respective odds ratio of 5.49 (95% CI 1.92–17.9), 4.37 (95% CI 4.37–465.7), and 1.084 (1.084–16.2). Mean length of hospital stay was significantly longer in patients presenting with AKI than in controls (respectively 52.4±22.1 days vs. 39.6±12.6, P<0.005). ConclusionAKI is very frequent during IE, particularly in patients with prosthetic valve IE, cardiac failure, and those receiving vancomycin.

Clinical predictors of complications in patients with left–sided infective endocarditis: A retrospective study of 206 episodes

Early identification of specific patient subgroups at high risk of developing life-threatening infective endocarditis (IE) complications is of paramount importance. Better stratification may allow more intensive treatment of these patients and positively influences clinical outcomes. We carried out a retrospective survey of consecutive left-sided IE adult patients, admitted over a 15-year period to two main tertiary care centres in the Czech Republic. Among a group of 196 patients (155 males; median age 64 years), a total of 206 left-sided IE episodes were identified. Perivalvular extension of infection was most frequently seen in prosthetic aortic valve endocarditis (OR 6.706, p<0.0001). Valve prolapse/perforation during IE episodes was significantly associated with mitral valve IE (OR 2.136, p=0.026) and vegetation length (OR 1.055, p=0.009). Septic shock was significantly related to two main risk factors: S. aureus infection (OR 8.459, p=<0.0001) and smoking (OR 8.403, p=0.001). Mitral valve IE with a vegetation length ≥13 mm was the strongest risk factor for this complication (OR 3.24, p=0.001), followed by S. aureus infection (OR 3.59, p=0.002). Finally, septic shock (OR 6.000, p=0.001) represented the most important risk factor of in-hospital mortality. This study provides the most detailed profile of complication predictors related to left-sided IE in Central Europe. Early individual stratification of IE related occurrence of complications might help to decrease extremely high morbidity and mortality of this disease (Tab. 5, Ref. 37).

Epidemiological and clinical profile of infective endocarditis at a Brazilian tertiary care center: an eight-year prospective study.

Infective endocarditis (IE) is a systemic infectious disease requiring a multidisciplinary team for treatment. This study presents the epidemiological and clinical data of 73 cases of IE in Rio de Janeiro, Brazil. This observational prospective cohort study of endocarditis patients during an eight-year study period described 73 episodes of IE in 70 patients (three had IE twice). Community-associated (CAIE) and healthcare-acquired infective endocarditis (HAIE) were diagnosed according to the modified Duke criteria. The collected data included demographic, epidemiologic, and clinical characteristics, including results of blood cultures, echocardiographic findings, surgical interventions, and outcome. Analysis of data from the eight-year study period and 73 cases (70 patients) of IE showed a mean age of 46 years (SD=2.5 years; 1-84 years) and that 65.7% were male patients. The prevalence of CAIE and HAIE was 32.9% and 67.1%, respectively. Staphylococcus aureus (30.1%), Enterococcus spp. (19.1%), and Streptococcus spp. (15.0%) were the prevalent microorganisms. The relevant signals and symptoms were fever (97.2%; mean 38.6 + 0.05°C) and heart murmur (87.6%). Vegetations were observed in the mitral (41.1%) and aortic (27.4%) valves. The mortality rate of the cases was 47.9%. In multivariate analysis, chronic renal failure (relative risk [RR]= 1.60; 95% confidence interval [CI] 1.01-2.55), septic shock (RR= 2.19; 95% CI 1.499-3.22), and age over 60 years (RR= 2.28; 95% CI 1.44-3.59) were indirectly associated with in-hospital mortality. The best prognosis was related to the performance of cardiovascular surgery (hazard ratio [HR]= 0.51; 95% CI 0.26-0.99).

Management and Outcome of Infective endocarditis in adults with congenital heart disease

Causes, epidemiology and microbiology of infective endocarditis (IE) have evolved in recent decades. Although novel tools for diagnosis and therapeutic strategies have emerged, mortality and morbidity remained high. These trends may particularly concern the growing population of adults with congenital heart disease (ACHD) who have an increased risk for IE. We aimed to describe causes, management and outcome of IE in ACHD, and to analyze the risk factors for in-hospital death. From 1997 to 2017, 628 consecutive episodes of IE in adults were recorded in our center. Among them, 118 (18.7%) concerned 117 ACHD (mean age, 40 ± 17.7 years, 80.5% male). Endocarditis was classified according to the modified Duke criteria. Overall, 50.8% of patients had a simple CHD, 12,7% a moderate, and 36,4% a complex. A total of 37,3% were right sided IE (97,3% pulmonary site and 2,3% tricuspid valve). It was at least the second episode of IE for 18 patients (15.3%) and a predisposing event could be identified in only 30.3% cases. Oral streptococci and Staphylococcus aureus were the most frequently microorganisms isolated (31.1% and 25,4%, respectively). Surgical intervention was performed in 76 episodes (64,5%). In-hospital mortality was 10.2% and was directly related to IE in 9/12 cases. On univariate analysis, risk factors for death were complexity of CHD (OR = 7.2, 95% CI[1.1–48.2] and OR = 5.3 95% CI[1.0–27.1] for moderate and complex CHD respectively, P ≤ 0.04), numbers of sternotomies ≥ 2 (OR = 5.1, 95% CI[1.2–21.2], P = 0.02), and leukocytes number (OR = 1.1, 95% CI[1.0–1.2], P < 0.01). On multivariate analysis complex CHD lesions were the strongest predictor for death (0.02). Mortality associated with IE in ACHD patients is lower than reported in acquired heart disease. Multidisciplinary approach by IE team and GUCH specialists may have improved management and outcome in this setting. However, risk for death remains high in complex lesions.

Infective Endocarditis by Rare Organism Granulicatella Adiacens

Infective endocarditis (IE) is a life-threatening infection of the cardiac valves especially in patients with preexisted valvular disease. Having a rheumatic heart disease, congenital heart disease, prosthetic valves or previous episodes of IE are some of the traditional risk factors for infective endocarditis (Hoen &amp; Duval, 2013).&#x0D; Although most cases were reported by streptococci especially streptococcus viridans, which is one of the commensal bacteria isolated from the mouth, some of the cases of IE can be caused by fastidious extracellular bacteria such as Abiotrophia, HACEK group bacteria, Clostridium, Brucella, Legionella, Mycobacterium, and Bartonella spp. These organisms need supplemented media, prolonged incubation time, and special culture conditions to grow and be isolated.&#x0D; Abiotrophia was reclassified in a new genus Granulicatella, as Granulicatella adiacens, balaenopterae, elegans and G. para adiacens. The genus Abiotrophia consists of only one species -A.defectiva.

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.

1079. When Does a Trans-Esophageal Echocardiogram (TEE) Change Management of Staphylococcus aureus Bacteremia (SAB)?

BackgroundThe recognition of infective endocarditis (IE) as a serious complication of SAB has led to a low threshold for echocardiography, extended treatment (eTx) with anti-staphylococcal agents (anti-SA), and even surgery. However, indications for eTx outside of IE are numerous. We sought to determine the frequency in which findings from a TEE changed clinical SAB management.MethodsAdults with SAB within the Calgary Health Zone between 2012 and 2014 were included if both a transthoracic echocardiogram (TTE) and TEE were performed within 7 days of each other. Patients potentially benefiting from eTx courses were a priori defined as having ≥1 of; (1) metastatic phenomena, (2) complicated SAB (defined as community acquired (CA), persistent fever/bacteremia at ≥48 hours), (3) intracardiac devices, and/or (4) Duke criteria defined IE (separately evaluated using TTE or TEE). Patient demographics, treatment (including changes to anti-SA duration and surgical indications), and clinical outcomes were extracted and evaluated.ResultsOf 961 SAB episodes, 179 (18% MRSA) met inclusion criteria (median 3.0 days, IQR 1.9–5.1 between TTE and TEE). Within the cohort 29% (n = 51) had metastatic phenomena (intracranial; 9% [n = 16], vertebral; 8% [n = 14]; empyema; 6% [n = 11]). Complicated bacteremia was present in 89% (n = 159), while 13% (n = 23) had intravascular hardware (39% pacemakers, 65% valve prostheses). IE was diagnosed in 22% (n = 40) of SAB episodes, with TTE identifying 58% of vegetations (n = 23) and TEE identifying an additional 30% (n = 15). Of the cohort, 89% (n = 160), 37% (n = 67), 4% (n = 7) of SAB had ≥1, 2, and 3 nonechocardiographic indications for eTx, respectively. Only one patient met criteria for eTx solely based on IE diagnosed from concordant TTE and TEE. Actual duration of therapy did not differ in SAB episodes that had ≥1 a priori eTx criteria but had a negative TEE relative to those who had a positive TEE (36.7 days, IQR 23.4–48.6 vs. 43.8 days, IQR 33.3–49.5, P = 0.17). Of the 15 episodes of TEE-only evident IE, 14 were CA, 12 had prolonged BSI, and nine embolic phenomena. Only 11 patients in the cohort required cardiac surgery, none were identified exclusively by TEE.ConclusionRoutine performance of TEE may not be required in all SAB as many patients have alternate indications for eTx with anti-SA regardless of TEE findings.Disclosures All authors: No reported disclosures.

Clinical Characteristics and Factors Associated With Mortality in First-Episode Infective Endocarditis Among Persons Who Inject Drugs

Persons who inject drugs (PWID) represent a distinct demographic of patients with infective endocarditis. Many centers do not perform valvular surgery on these patients owing to concerns about poor outcomes. Addiction services are underused in hospitals. To compare clinical characteristics in first-episode infective endocarditis in PWID who are surgically vs medically managed and to identify variables associated with mortality. This case series studied PWID treated for a first episode of infective endocarditis between April 1, 2007, and March 30, 2016. Participants were adult patients (aged ≥18 years) admitted to any of 3 hospitals in London, Ontario, Canada. Analysis occurred between July 2016 and November 2017. Survival among PWID; the causative organisms, site of infection, and cardiac as well as noncardiac complications; referral to addiction services; and surgical vs medical management. Of 370 total first-episode cases of infective endocarditis, 202 (54.6%) were in PWID. Among PWID, 105 (52%) were male, the median (interquartile range) age was 34 (28-42) years, and patients were predominantly positive for the hepatitis C virus (69.8% [141 of 202]). Right-sided infection was more common (61.4% [124 of 202]), and most infections were caused by Staphylococcus aureus (77.2% [156 of 202]). Surgery occurred in 19.3% of patients (39 of 202). The all-cause mortality rate was 33.7% (68 of 202). Adjusting for age and sex, survival analysis demonstrated that surgery was associated with lower mortality (hazard ratio [HR], 0.44; 95% CI, 0.23-0.84; P = .01), as was referral to addiction treatment (HR, 0.29; 95% CI, 0.12-0.73; P = .008). Higher mortality was associated with left-sided infection (HR, 3.26; 95% CI, 1.82-5.84; P < .001) and bilateral involvement (HR, 4.51; 95% CI, 2.01-10.1; P < .001). This study presents the demographic characteristics of first-episode infective endocarditis in PWID. Results highlight the potentially important role of addictions treatment in this population. Further study to optimize selection criteria for surgery in PWID is warranted.

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.