High Risk Of Infective Endocarditis Research Articles

Perioperative Antibiotic Use of Dermatologic Surgeons in 2012

Recommendations for antibiotic prophylaxis in dermatologic surgery have been established, but there is variability in perioperative antibiotic use of dermatologists. Authoritative guidelines have shifted away from routine use of antibiotic prophylaxis because there is no conclusive evidence that antibiotic use reduces risk of infective endocarditis or prosthetic joint infection. To determine current practices of perioperative antibiotic use of Mohs-trained surgeons and to compare patterns of use with updated administration guidelines. A survey was sent to American College of Mohs Surgery members in 2012. The main outcome measures were survey responses relating to demographic characteristics, experience with postoperative infection, familiarity with antibiotic guidelines, perioperative antibiotic practices, attitudes regarding antibiotic use, and antibiotic selection. Most survey respondents are familiar with the Antibiotic Prophylaxis in Dermatologic Surgery Advisory Statement 2008, but respondents give antibiotics for more indications than are recommended. Although not recommended, a high percentage reported giving antibiotics to patients at high risk of infective endocarditis or joint infection even when surgery does not breach oral mucosa or involve infected skin. Dermatologic surgeons overuse perioperative antibiotics for prevention of surgical site infection, infective endocarditis, and prosthetic joint infection based on current recommendations.

Doctor, my dentist wants your opinion

Dental surgery is very common, and it is important for our dental colleagues to understand the medical history and chronic medications of our co-managed patients. Antibiotic prophylaxis is currently recommended only for patients at high risk for infective endocarditis when undergoing high-risk dental procedures. Good dental hygiene can prevent more infective endocarditis than prophylactic antibiotic therapy, as transient bacteraemia is common in daily activities such as the brushing and flossing of teeth. Most dental surgeries can generally be performed on patients taking a daily dose of aspirin, but the dentist must be able to assess the risk-benefit ratio of employing local measures of haemostasis versus stopping the antiplatelet therapy. Patients on antiplatelet with recent coronary artery stenting should be referred to their primary cardiologist regarding the cessation of these agents before any surgery.

NICE guidance on antibiotic prophylaxis to prevent infective endocarditis: a survey of clinicians' attitudes

Since the introduction of the National Institute for Health and Clinical Excellence (NICE) guideline (CG064) in 2008 recommending cessation of antibiotic prophylaxis (AP) against infective endocarditis (IE), low level prescribing persists in the UK and is a potential reason why there has been no significant change in the general upward trend in cases of IE. To undertake a survey of dentists (Ds), cardiologists and cardiothoracic surgeons (C/CTSs) and infection specialists (ISs) to determine why this might be the case. Internet questionnaire-based survey. A questionnaire was distributed by email to specialists via UK national societies. A total of 1168 responses were received. All the specialist groups are aware of the guideline (99%). Ds are broadly satisfied, whereas C/CTSs are not. Most Ds follow the NICE guidance (87%), whereas many C/CTSs (39%) do not; ISs adopt a middle course (56%). Even amongst Ds, a significant proportion believe that patients with a prosthetic heart valve (25%) or previous history of IE (38%) should receive AP. A total of 36% of Ds have prescribed AP since March 2008 and many have undertaken procedures where AP has been prescribed by someone else. The majority of respondents (65%) feel that more evidence is required, preferably in the form of a randomized controlled trial. Many patients perceived to be at high risk of IE are still receiving AP in conflict with current NICE guidance.

A narrative review of infections associated with personal service establishments Part II: Piercing and tattooing

In part II of our paper on personal service establishment services-related infections, we review bacterial, viral, and fungal infections related to piercing, tattooing, and body modification. Sixty-six studies were identified for piercing and tattooing-related viral and bacterial infections. No studies investigating fungal infections, or body modification service-related infections were identified. Bacterial infections, particularly, mycobacterium infections were commonly reported for piercing and tattooing, while viral risks were less well characterized, with the exception of tattooing related hepatitis B and C infections. Aside from localized infections at the pierced or tattooed site, a systemic infection involving the outer lining of the heart, infective endocarditis (IE), was also identified as an important health concern; those with pre-existing heart conditions are at highest risk of IE from invasive procedures. Both bacterial and viral outbreaks were linked to poor infection control procedures, and in two events, the use of municipal water to dilute tattoo ink was suspected as a source of mycobacteria leading to outbreaks of infection. The majority of studies identified were case reports; these studies provide only a limited understanding of infection pathways and do not allow for a quantitative estimation of risk. Despite important gaps in current knowledge, the available scientific literature can be used to support and inform the development of health-protective policies and practices in personal service establishments.

Bacteremia During Quinsy and Elective Tonsillectomy

Bacteremia during elective tonsillectomy is well recognized, whereas bacteremia during quinsy tonsillectomy has never been studied. The aim of the present study was to explore the incidence of bacteremia during elective and quinsy tonsillectomy in order to evaluate the antibiotic prophylaxis recommendations to patients at high risk of infective endocarditis who are undergoing tonsillectomy. A prospective study was conducted on 80 patients undergoing elective tonsillectomy and 36 patients undergoing acute tonsillectomy due to peritonsillar abscess. Blood cultures, tonsillar swabs, core tissue, and pus aspirates were analyzed by standard microbiological techniques. Bacteremia was detected in 73% of patients during elective tonsillectomy compared to 56% during quinsy tonsillectomy (P = .089, Fishers exact test). Significantly more blood culture bottles were positive for each isolate obtained from elective tonsillectomy cases compared to quinsy tonsillectomy cases (P < .001, Spearman rank correlation). In all, 59% and 42% of electively and acutely tonsillectomized patients, respectively, had bacteremia with microorganisms that are predominant in bacterial endocarditis. Ninety-three percent of the isolated strains were sensitive to amoxicillin, and all were sensitive to amoxicillin with clavulanic acid. Our results challenge the distinction made by the European Society of Cardiology between elective and quinsy tonsillectomy, with regard to antibiotic prophylaxis recommendation only to patients undergoing procedures to treat an established infection. To provide full empiric coverage, including coverage for Staphylococcus aureus, we advocate the use of amoxicillin with clavulanic acid in patients at high risk of infective endocarditis.

Natural and unnatural history of tetralogy of Fallot repaired during adolescence and adulthood

Surgical repair of tetralogy of Fallot (TOF) in countries with sound medical care systems is seldom delayed until adolescence. This study investigated the clinical profile and the surgical outcomes in such a population from Taiwan. Between 1970 and 2009, 179 TOF patients (56% male) received total repair at 19.2 ± 8.3 (10-49) years of age. We reviewed the medical records and interviewed the patients concerning their current status. The survival was ascertained in all by a link to our national health database. Major morbidities before cardiac repair included atrial arrhythmia (1.1%), ventricular arrhythmia (3.9%), infective endocarditis (6.7%), brain abscess (4.6%) and pulmonary tuberculosis (3.3%). Ventricular arrhythmia and pulmonary tuberculosis occurred mainly after 20 years of age. Thirty patients (16.8%) received a palliative shunt. The preoperative QRS duration increment was 0.6 ms/year. Early mortality occurred in 4 (2.2%) and was related to previous shunt surgery (OR = 16.5, p < 0.05) and coronary artery crossing RVOT (OR 17.6, p < 0.05). After repair, the functional class improved in all patients. The median age at latest follow-up was 31.8 (32.8 ± 12.3) years. The survival was 92.7 and 89.3% at 20 and 30 years after operation, respectively. Late cardiovascular death could be predicted by the length of postoperative intensive care unit stay (OR = 1.3, p < 0.001). The freedom from ventricular arrhythmia 30 years after repair was 84.1% and was associated with a final QRS longer than 160 ms. Unrepaired TOF patients were at high risk of infective endocarditis, brain abscess, pulmonary tuberculosis and arrhythmias during their adolescence and adulthood. Cardiac repair in this age group was still safe and effective.

Turning 18 with congenital heart disease: prediction of infective endocarditis based on a large population

The risk of infective endocarditis (IE) in adults with congenital heart disease is known to be increased, yet empirical risk estimates are lacking. We sought to predict the occurrence of IE in patients with congenital heart disease at the transition from childhood into adulthood. We identified patients from the CONCOR national registry for adults with congenital heart disease. Potential predictors included patient characteristics, and complications and interventions in childhood. The outcome measure was the occurrence of IE up to the age of 40 and 60. A prediction model was derived using the Cox proportional hazards model and bootstrapping techniques. The model was transformed into a clinically applicable risk score. Of 10 210 patients, 233 (2.3%) developed adult-onset IE during 220 688 patient-years. Predictors of IE were gender, main congenital heart defect, multiple heart defects, and three types of complications in childhood. Up to the age of 40, patients with a low predicted risk (<3%) had an observed incidence of less than 1%; those with a high predicted risk (≥3%) had an observed incidence of 6%. The model also yielded accurate predictions up to the age of 60. Among young adult patients with congenital heart disease, the use of six simple clinical parameters can accurately predict patients at relatively low or high risk of IE. After confirmation in other cohorts, application of the prediction model may lead to individually tailored medical surveillance and educational counselling, thus averting IE or enabling timely detection in adult patients with congenital heart disease.

The oral health of children considered very high risk for infective endocarditis

Children with previous experience of infective endocarditis or with prosthetic heart valve are considered at very high risk for infective endocarditis. The aim of this study was to compare the dental health of a group of these children with a group of healthy controls and to determine parental awareness of the importance of good oral health. Oral examination was carried out in 28 children with previous infective endocarditis or a prosthetic heart valve to assess oral health. Findings were compared to a healthy control group of 28. Questionnaires were distributed to the parents to assess awareness of oral health. There was no significant difference in DMFT scores of study and control group (2.43 +/- 3.72 and 1.36 +/- 2.5 respectively) or in DMFT scores of study and control group (1.5 +/- 1.73 and 1.15 +/- 1.42 respectively), 36% of the study group had untreated caries. Parental knowledge of the link between oral health and infective endocarditis was excellent. There were no significant differences between the oral health of cardiac children and healthy children although the dmft and DMFT scores of the study group were high. Of concern was the proportion of children with untreated caries in spite of good dental awareness and attendance.

Infective endocarditis following gastrointestinal and genitourinary procedures: An argument in favour of prophylaxis

In the 2007 American Heart Association guidelines, gastrointestinal (GI) and genitourinary (GU) procedures were removed from the indications for infective endocarditis (IE) prophylaxis. The purpose of this study was to estimate the contribution of GI and GU procedures to the occurrence of IE in order to appreciate whether this removal was justified. Among 212 episodes of IE prospectively collected during 7 y, 20 cases (9%) had invasive GI and GU procedures and 17 (8%) had dental interventions within 3 months before IE diagnosis. Enteric organisms (predominantly Enterococcus faecalis) were significantly more common in the GI and GU group than in all other patients, whereas viridans streptococci, the most common pathogen in the dental group, were absent from the GI and GU group. This unique combination of pathogens in the GI and GU group is highly suggestive of a true association between the procedure and IE. Hence, GI and GU procedures pose a non-negligible risk of acquisition of IE. Consequently, it is proposed here, that adults at high risk of IE who undergo surgical GI and GU procedures, receive prophylaxis that includes an anti-enterococcal agent.

Current Features of Infective Endocarditis in Elderly Patients

Elderly patients are emerging as a population at high risk for infective endocarditis (IE). However, adequately sized prospective studies on the features of IE in elderly patients are lacking. In this multinational, prospective, observational cohort study within the International Collaboration on Endocarditis, 2759 consecutive patients were enrolled from June 15, 2000, to December 1, 2005; 1056 patients with IE 65 years or older were compared with 1703 patients younger than 65 years. Risk factors, predisposing conditions, origin, clinical features, course, and outcome of IE were comprehensively analyzed. Elderly patients reported more frequently a hospitalization or an invasive procedure before IE onset. Diabetes mellitus and genitourinary and gastrointestinal cancer were the major predisposing conditions. Blood culture yield was higher among elderly patients with IE. The leading causative organism was Staphylococcus aureus, with a higher rate of methicillin resistance. Streptococcus bovis and enterococci were also significantly more prevalent. The clinical presentation of elderly patients with IE was remarkable for lower rates of embolism, immune-mediated phenomena, or septic complications. At both echocardiography and surgery, fewer vegetations and more abscesses were found, and the gain in the diagnostic yield of transesophageal echocardiography was significantly larger. Significantly fewer elderly patients underwent cardiac surgery (38.9% vs 53.5%; P < .001). Elderly patients with IE showed a higher rate of in-hospital death (24.9% vs 12.8%; P < .001), and age older than 65 years was an independent predictor of mortality. In this large prospective study, increasing age emerges as a major determinant of the clinical characteristics of IE. Lower rates of surgical treatment and high mortality are the most prominent features of elderly patients with IE. Efforts should be made to prevent health care-associated acquisition and improve outcomes in this major subgroup of patients with IE.

Infective Endocarditis in Patients with Kidney Failure: Chronic Dialysis and Kidney Transplant.

Physicians who treat patients with infective endocarditis (IE) are encountering a growing number of dialysis and kidney transplant patients. Both groups have 30 to 100 times higher risk of IE, with 1-year mortalities of 40% to 60%. The predominant organisms causing IE are gram positive, with 60% to 80% of cases due to Staphylococcus aureus, and another 10% to 20% of cases due to coagulase-negative staphylococci. Renal transplant patients may develop fungal IE, but this risk is primarily in the first 3 months after transplant. In addition to blood cultures, transesophageal echocardiogram is the most useful diagnostic examination for IE in these patients. Initial antibiotic therapy, pending final culture and antibiotic susceptibility results, should provide coverage against the most common organisms and allow for the potential of either methicillin or vancomycin-resistant species. Removal of infected hemodialysis access devices and at least 4 to 6 weeks of intravenous antibiotics are recommended. Antibiotic prophylaxis against IE has been recommended for all dialysis and renal transplant patients, but this strategy is controversial and unproven.

Procedures associated with infective endocarditis in adults

To assess the relative risk of infective endocarditis associated with various procedures and the protective efficacy of antibiotic prophylaxis by a case-control study. Recommendations for the prevention of infective endocarditis are based on the hypothesis of a relationship between procedures and infective endocarditis which is supported by anecdotal reports and data from experimental models. Cases met the Von Reyn's diagnostic criteria modified with echocardiographic and macroscopic findings Controls were recruited from cardiology or medicinal wards. Cases (n = 171) and controls were matched as regards sex, age and underlying cardiac condition. They were requested to indicate all the medical, surgical or dental procedures within the previous 3 months. Among potential confounding factors, infectious episodes and skin wounds in the previous 3 months were reported. Antibiotic prophylaxis administration was documented for type, dosage, duration and administration schedule. Cases significantly more frequently than controls had undergone at least one procedure (matched odds ratio, 1.6; 95% confidence interval, 1.01 to 2.53). Dental procedures considered as a whole were not associated with an increased risk, although scaling and root canal treatment showed a trend towards a higher risk of infective endocarditis (P = 0.065). Among non-dental procedures, only surgery appeared to be at risk (matched odds ratio, 4.7; 95% confidence interval, 1.02 to 22). Considering all procedures, the risk of infective endocarditis increased significantly with the number of procedures. While general co-morbid conditions did not differ between the two groups, cases significantly more frequently than controls had experienced an infectious episode or a skin wound. In multivariate analysis, only infectious episodes and skin wounds significantly increased the risk of infective endocarditis. Scaling was the only independent risk factor for viridans streptococcal infective endocarditis. The 46% protective efficacy of antibiotic prophylaxis was not significant. Procedures do increase the risk of infective endocarditis. The interpretation of the apparent low risk associated with dental procedures may be as a result of the current practice of antibiotic prophylaxis. Our data suggest that surgery should be more clearly mentioned in future guidelines, and reemphasize that a rigorous treatment of any focal infection in cardiac patients is mandatory. From the efficacy rate of antibiotic prophylaxis,it can be estimated that the overall incidence of infective endocarditis might be reduced by 5 to 10% in France by appropriate use of antibiotic prophylaxis in cardiac patients.

Prophylaxie de l'endocardite infectieuse

An antibiotic prophylaxis of infective endocarditis is recommended in patients at high risk for infective endocarditis (patients with valvular prosthesis, or cyanogen congenital or obstructive cardiac defect) or those with aortic, mitral or tricuspid valvulopathy, a non-cyanogen congenital or obstructive cardiac defect. Dental procedures (except treatment for superficial decay and preparation for the fitting of prostheses to teeth with intact pulp) are to be carried out under local antisepsis and a prophylactic antibiotics, such as 3 g of oral amoxicillin or in case of allergy to penicillin, 600 mg of clindamycin or 1g of pristinamycin, adminstered one hour prior to the procedure. A similar prophylaxis is recommended for the procedures on the upper respiratory tract. Amoxicillin, or vancomycin or teicoplanin are recommended for procedures under general anaesthesia. For surgery on the intestinal or urogenital tract, regimens combine amoxicillin with gentamicin, or in case of allergy to penicillin, vancomycin or teicoplanin with gentamicin.

MITRAL VALVE PROLAPSE AS A RISK FACTOR FOR INFECTIVE ENDOCARDITIS

The frequency of mitral valve prolapse was assessed in 48 patients with mitral valve endocarditis and in 96 controls matched for age and sex, attending a routine family screening clinic or having surgery of the limbs. The frequency of mitral valve prolapse in cases with endocarditis (9 of 48 patients) was more than three times that in controls (6 of 96) (odds ratio 3·5; 95% confidence interval [CI] 1·1-10·5). When patients with rheumatic heart disease, an established risk factor for infective endocarditis, were excluded from the study group, patients were nearly six times more likely to have infective endocarditis than were controls (odds radio 5·7; 95% CI 1·8-18·4). However, a higher risk of infective endocarditis was seen only in the subjects with mitral valve prolapse and a previously known systolic murmur (odds ratio 14·5; 95% CI 1·7-125). The results indicate that mitral valve prolapse constitutes a true risk factor for infective endocarditis only when associated with the presence of a precordial systolic murmur.