Nosocomial Infective Endocarditis Research Articles

Non-nosocomial Healthcare-Associated Infective Endocarditis: A Distinct Entity? Data From the GAMES Series (2008-2021).

Patients who acquire infective endocarditis (IE) following contact with the healthcare system, but outside the hospital, are classified as having non-nosocomial healthcare-associated IE (HCIE). Our aim was to characterize HCIE and establish whether its etiology, diagnosis, and therapeutic approach suggest it should be considered a distinct entity. This study retrospectively analyzes data from a nationwide, multicenter, prospective cohort including consecutive cases of IE at 45 hospitals across Spain from 2008 to 2021. HCIE was defined as IE detected in patients in close contact with the healthcare system (eg, patients receiving intravenous treatment, hemodialysis, or institutionalized). The prevalence and main characteristics of HCIE were examined and compared with those of community-acquired IE (CIE) and nosocomial IE (NIE) and with literature data. IE was diagnosed in 4520 cases, of which 2854 (63%) were classified as CIE, 1209 (27%) as NIE, and 457 (10%) as HCIE. Patients with HCIE showed a high burden of comorbidities, a high presence of intravascular catheters, and a predominant staphylococcal etiology, Staphylococcus aureus being identified as the most frequent causative agent (35%). They also experienced more persistent bacteremia, underwent fewer surgeries, and showed a higher mortality rate than those with CIE (32.4% vs 22.6%). However, mortality in this group was similar to that recorded for NIE (32.4% vs 34.9%, respectively, P = .40). Our data do not support considering HCIE as a distinct entity. HCIE affects a substantial number of patients, is associated with a high mortality, and shares many characteristics with NIE.

Comparing Treatment Outcomes of Ampicillin-Sulbactam, Other β-Lactams, and Vancomycin in Blood Culture-Negative Infective Endocarditis.

Selection of proper antibiotics for blood culture-negative infective endocarditis (BCNIE) is difficult due to limited data on antibiotic regimens for BCNIE in existing literature. The aim of this study was to compare ampicillin-sulbactam, other β-lactams antibiotics, and vancomycin among patients with BCNIE to determine the proper antibiotic regimens. This retrospective study included adult patients with BCNIE admitted to Severance Hospital from November 2005 to August 2017. Patients were classified into three groups as, treated with ampicillin-sulbactam, other β-lactams, and vancomycin. The primary outcome was 1-year all-cause mortality. A total of 74 cases with BCNIE were enrolled in this study. There were no statistically significant differences in clinical characteristics between the three groups. One-year mortality did not significantly differ between the study groups either. Further, in-hospital mortality, 28-day mortality and overall mortality showed no difference. However, Cox-regression analysis showed nosocomial infective endocarditis as an independent risk factor and a protective effect of surgery on 1-year mortality. This study showed no clear difference in the outcomes of BCNIE as per the antibiotic therapy but suggested the beneficial effect of surgical treatment. With increasing global concern of antimicrobial resistance, it might be reasonable to select ampicillin-sulbactam-based antibiotic therapy while actively considering surgical treatment in BCNIE.

In-hospital Outcomes of Infective Endocarditis from 1978 to 2015: Analysis Through Machine-Learning Techniques

BackgroundEarly identification of patients with infective endocarditis (IE) at higher risk for in-hospital mortality is essential to guide management and improve prognosis. MethodsA retrospective analysis was conducted of a cohort of patients followed up from 1978 to 2015, classified according to the modified Duke criteria. Clinical parameters, echocardiographic data, and blood cultures were assessed. Techniques of machine learning, such as the classification tree, were used to explain the association between clinical characteristics and in-hospital mortality. Additionally, the log-linear model and graphical random forests (GRaFo) representation were used to assess the degree of dependence among in-hospital outcomes of IE. ResultsThis study analyzed 653 patients: 449 (69.0%) with definite IE; 204 (31.0%) with possible IE; mean age, 41.3 ± 19.2 years; 420 (64%) men. Mode of IE acquisition: community-acquired (67.6%), nosocomial (17.0%), undetermined (15.4%). Complications occurred in 547 patients (83.7%), the most frequent being heart failure (47.0%), neurologic complications (30.7%), and dialysis-dependent renal failure (6.5%). In-hospital mortality was 36.0%. The classification tree analysis identified subgroups with higher in-hospital mortality: patients with community-acquired IE and peripheral stigmata on admission; and patients with nosocomial IE. The log-linear model showed that surgical treatment was related to higher in-hospital mortality in patients with neurologic complications. ConclusionsThe use of a machine-learning model allowed identification of subgroups of patients at higher risk for in-hospital mortality. Peripheral stigmata, nosocomial IE, absence of vegetation, and surgery in the presence of neurologic complications are predictors of fatal outcomes in machine learning–based analysis.

P266 Infective endocarditis: exploring geographical trends and comparing risk models in a multi-ethnic asian population

Abstract Background Host factors and complications have been associated with higher mortality in infective endocarditis (IE). We explored factors impacting mortality in our local multiracial Singapore population and validated the simplified risk score to predict 6-month mortality in IE developed by the International Collaboration on Endocarditis [ICE]. Methods Using a retrospective registry of definite IE determined by the Duke’s criteria, we studied 116 IE cases diagnosed between January 2010 and December 2014. Baseline demographic, clinical and 6 month mortality data were collected. Logistic and Cox regression was used to study factors affecting 6 month mortality. A cut-off of p < 0.10 was used to determine factors to be put into the multivariable model. Results 6 month mortality in the cohort was 26.7% [31/116]. Surgery during index hospitalization was performed in 20.7% [24/116] of the cohort. Significant factors affecting mortality include: [Host] diabetes mellitus, intravenous drug abuser, [IE characteristics] left sided valve regurgitation, nosocomial IE, [IE complications] persistent bacteremia, stroke and embolic phenomena. Surgery was significantly associated with lower risk of mortality. The receiver operating curve(ROC) of the ICE simplified risk score is 0.84. Using the principle of parsimony, we compared our reduced model, removing variables (possible to state what are the variables removed to compare and contrast the 2 models) with p-value > 0.10, the ROC of our reduced model is 0.85 and difference between performance of both models were non-significant at p = 0.893. The goodness-of-fit of both models were demonstrated by non significant Hosmer-Lemeshow test. K-fold cross validation was also performed for internal validation of our reduced model. Conclusions 6 month mortality after IE is 26.7% and is predicted by host factors, IE characteristics and complications. Surgery during the index hospitalization is associated with lower mortality. Our reduced IE model performed comparatively to the ICE risk score.

Infective endocarditis: A changing epidemiological profile over the years: A prospective cohort study

Epidemiological features of infective endocarditis (IE) have changed during the last decades because of an increase in degenerative valvular disease in the elderly, placement of prosthetic valves, and exposure to invasive procedures. Although lower mortality rates have been observed, overall mortality remains high. The aim of this study was to analyse epidemiology, and predictors of 6-month mortality in IE. This was a prospective study that enrolled 240 patients admitted for IE in the cardiology department of Monastir hospital between 1983 and 2017. Included Patients had definite IE according to the modified Ducke criteria. Thirty-two percent of episodes involved prosthetic valves. Thirty percent of episodes were nosocomial. Thirty-three percent included staphylococci, 22% streptococci, and 10% enterococci. At least one complication occurred in 59% of the episodes and 43% had surgical intervention. Six-month mortality was 20%: 29% for staphylococci, 19% for enterococci, and 9% for streptococci. Seventy-one percent of patients with a contraindication to surgery died when compared with 7% with medical treatment without a contraindication and 13% with surgical treatment. In multivariable logistic regression, predictors of 6-month mortality were age ( P = 0.04), the causative microorganism ( P = 0.03), and treatment group ( P = 0.03). Compared with older series, we observed more prosthetic valve IE, nosocomial IE, and surgery. Staphylococcus aureus was the predominant microorganism. Age, staphylococci, and the contraindication to surgery were the main predictors of 6-month mortality.

Nosocomial Vs. Community-Acquired Infective Endocarditis in Spain: Location, Trends, Clinical Presentation, Etiology, and Survival in the 21st Century.

Major changes have occurred in the epidemiology and etiology of infective endocarditis (IE). Nevertheless, the differences between nosocomial infective endocarditis (NIE) and community-acquired infective endocarditis (CIE) have not been addressed in a population-based study. We conducted a retrospective, nationwide, temporal trend study from 1997 to 2014 analyzing the epidemiology, clinical, geographical, meteorological characteristics of patients diagnosed with IE in Spain, to distinguish NIE from CIE. Among 25,952 patients with IE (62.2 ± 18·6 years; 65.9% men), 45.9% had NIE. The incidence of IE increased from 2.83 to 3.73 due to the NIE incidence increment with a decline in CIE. Patients with NIE were older (63.8 years vs. 60.8 years, p < 0·001), presented a higher Charlson index (1.22 vs. 1.03, p < 0.001), a greater history of implanted cardiac devices (8.7% vs. 4.6%, p < 0.001), and higher mortality (31.5% vs. 21.7%, p < 0.001). The most frequent microorganism for both NIE and CIE was Staphylococcus (p < 0.001), and the North reported a higher incidence (p < 0.001). Risk factors of mortality for NIE were age, Charlson index, hemodialysis, shock, heart failure, and stroke. Risk factors for CIE included female sex, renal disease, and cardiac-device carriers. The etiology of IE shifted from community origins to mostly nosocomial-associated infections. Higher morbidity, mortality, and poorer outcomes are associated with NIE.

Infective endocarditis: A changing epidemiological profile over the years: A prospective cohort study

Epidemiological features of infective endocarditis have changed during the last decades because of an increase in degenerative valvular disease in the elderly, placement of prosthetic valves, and exposure to invasive procedures. Although lower mortality rates have been observed over the last decades, overall mortality remains high. This was a prospective study which included all patients diagnosed with infective endocarditis (IE) and hospitalized in the cardiology department of Monastir hospital between 1983 and 2017. We included patients who were diagnosed with definite infective endocarditis based on the modified Ducke criteria. And the aim was to analyse epidemiology, and predictors of 6-month mortality in infective endocarditis. A prospective observational cohort study included 240 patients with definite IE. Thirty-two percent of episodes involved prosthetic valves. Thirty percent of episodes were nosocomial. Thirty-three percent included staphylococci, 22% streptococci, and 10% enterococci. At least one complication occurred in 59% of the episodes and 43% had surgical intervention. Six-month mortality was 20%: 29% for staphylococci, 19% for enterococci, and 9% for streptococci. Seventy-one percent of patients with a contraindication to surgery died when compared with 7% with medical treatment without a contraindication and 13% with surgical treatment. In multivariable logistic regression, predictors of 6-month mortality were age ( P = 0.04), the causative microorganism ( P = 0.03), and treatment group ( P = 0.03). Compared with older series, we observed more prosthetic valve IE, nosocomial IE, and surgery. Staphylococcus aureus was the predominant microorganism. Age, staphylococci, and the contraindication to surgery were the main predictors of 6-month mortality.

Infective Endocarditis in Cancer Patients - Causative Organisms, Predisposing Procedures, and Prognosis Differ From Infective Endocarditis in Non-Cancer Patients.

Infective endocarditis (IE) in cancer patients is increasing, but because little is known about it in these patients, we analyzed patient characteristics and outcomes and compared these factors in IE patients with and without cancer. Methods and Results: This retrospective cohort study included 170 patients with IE newly diagnosed between January 2011 and December 2015. Among 170 patients, 30 (17.6%) had active cancer. The median age of IE patients with cancer was higher than that of non-cancer patients. Nosocomial IE was more common in cancer patients. Non-dental procedures, such as intravenous catheter insertion and invasive endoscopic or genitourinary procedures, were more frequently performed before IE developed in cancer patients. Staphylococcus was the most common pathogen in cancer patients, whereas Streptococcus was the most common in non-cancer patients. In-hospital mortality was significantly higher in cancer patients with IE (34.4% vs. 12.4%, P<0.001). IE was an important reason for discontinuing antitumor therapy and withholding additional aggressive treatment in nearly all deceased cancer patients. IE is common in cancer patients and is associated with poorer outcomes. Patients with IE and cancer have different clinical characteristics. Additional studies regarding antibiotic prophylaxis before non-dental invasive procedures in cancer patients are needed, as cancer patients are not considered to be at higher risk of IE.

Risk factors for poor prognosis in nosocomial infective endocarditis.

Background/AimsThe aim of our study was to compare the characteristics of nosocomial infective endocarditis (NIE) with community-acquired infective endocarditis (CIE) and to determine independent risk factors for in-hospital death.MethodsWe retrospectively reviewed the medical records of 560 patients diagnosed with infective endocarditis. NIE was defined by a diagnosis made > 72 hours after hospital admission or within 2 months of hospital discharge.ResultsAmong the 560 cases reviewed, 121 were classified as NIE. Compared with patients with CIE, patients with NIE were older (mean ± SD, 51.30±18.01 vs. 59.76±14.87, p < 0.001). The in-hospital death rate of the NIE group was much higher than that of the CIE group (27.3% vs. 5.9%, p < 0.001). More patients with NIE had central intravenous catheters, and were undergoing hemodialysis (p < 0.001). Methicillin-resistant Staphylococcus aureus (MRSA) was the most common causal microorganism of NIE, and MRSA (p < 0.001) and fungus (p = 0.002) were more common in NIE compared with CIE. On multiple analysis, age, liver cirrhosis, cancer chemotherapy, central intravenous catheter, hemodialysis, and genitourinary tract manipulation were independent clinical risk factors for NIE. Among the patients with NIE, 33 died during their hospital admission. The independent risk factors for in-hospital death were older age (adjusted odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01 to 1.07; p = 0.037) and chemotherapy for malignancy (adjusted OR, 3.89; 95% CI, 1.18 to 12.87; p = 0.026).ConclusionsBecause of the considerable incidence of NIE and its poor prognosis, we should pay attention to early diagnosis and active management of NIE, especially for older patients and patients receiving chemotherapy.

Abstract 9865: A Validated, Simplified Risk Model for Predicting 6-Month Mortality in Infective Endocarditis

Introduction: Infective endocarditis (IE) is a disease with high in-hospital and longer term mortality. Hypothesis: A validated risk model of prognostic variables may improve clinical risk stratification. Methods: Using a large, multinational, prospective registry of definite IE (International Collaboration on Endocarditis-Prospective Cohort Study, 2000-2006, n=4066), a model to predict 6-month survival was developed by Cox proportional hazard modeling with inverse probability weighting for surgery treatment and internally validated by bootstrapping method. This model was externally validated in an independent prospective registry (ICE-PLUS, 2008-2012, n=1582). Results: Six-month mortality was 964/4066 (23.7%) in ICE-PCS and 346/1582 (21.9%) in ICE-PLUS cohorts. Surgery during the index hospitalization was performed in 49.5% and 56.0% of the cohorts, respectively. In the derivation model, variables related to host factors (age, dialysis), IE characteristics (prosthetic or nosocomial IE, causative organism, left-sided valve vegetation), and IE complications (severe heart failure, stroke, paravalvular complication, and persistent bacteremia) were independently associated with 6-month mortality, and surgery was associated with a lower risk of mortality (Harrell’s C statistic=0.715). In the validation model, these variables had similar hazard ratios (Harrell’s C statistic=0.682), with a similar, independent benefit of surgery (HR=0.74 [95% CI, 0.62-0.89]). Both models differentiated quintiles of risk for 6-month mortality. A simplified risk model was developed by weight-adjustment of these variables. Conclusions: Six-month mortality after IE is approximately 25% and predicted by host factors, IE characteristics, and IE complications. Surgery during the index hospitalization is associated with lower mortality. A simplified risk model may be used to identify specific risk sub-groups in IE.

Endocarditis due to gram-negative bacilli at a French teaching hospital over a 6-year period: clinical characteristics and outcome

Background: Infective endocarditis (IE) due to gram-negative bacilli (GNB) is rare. However, several studies described a change in the epidemiological profile of patients within the past few years. Methods: We reviewed all cases diagnosed and followed in the infectious diseases ward of a French teaching hospital in Paris between 2009 and 2014, inclusive. Results: Among the 17 patients with definite GNB-IE (11 male, mean age 54 years), 12 (70%) were due to non-HACEK GNB and 5 (30%) to HACEK group GNB. A prosthetic valve was involved in 10 cases (8 in non-HACEK and 2 in HACEK group). Escherichia coli (4/12 patients) and Pseudomonas aeruginosa (3/12 patients) were the most common pathogens in the first group; all the pathogens in the second group were Haemophilus spp. One-third of the patients with non-HACEK GNB had nosocomial IE, whereas injection drug use-related infections were rare (2/12). All patients with HACEK infection had at least one complication (intracardiac abscess, stroke or other systemic embolization). All patients were treated by antibiotic combination therapy during a median time of 42 days (interquartile range (IQR) = 42–42) and 10 (59%) underwent cardiac surgery. One death at 9 months was observed in the non-HACEK group. Conclusions: Regarding HACEK IE, this report supports the frequent association with vascular complications. Regarding non-HACEK GNB IE, this report supports the increasing proportion of nosocomial infections. We reported a high proportion of surgery in the therapeutic management of both HACEK and non-HACEK groups associated with no in-hospital mortality.

Infective Endocarditis.

Infective endocarditis (IE) is a noncontagious infection of the endocardium and heart valves. The epidemiology of IE has shifted recently with an increase in health care-associated IE. Infective endocarditis requiring intensive care unit stay is increasing, and nosocomial IE is frequently responsible. Diagnosis of IE requires multiple clinical data points encompassing history and physical examination, microbiology, and cardiac imaging as no one test is sufficiently sensitive or specific. The modified Duke criteria algorithm is the standard of care in the clinical diagnosis of IE. Complications from IE are common, particularly so in the critical care setting, and include congestive heart failure, embolism, septic shock, invasive infection, prosthetic valve dehiscence, heart block, and mycotic aneurysm. A multidisciplinary care team of infectious disease, cardiology, and cardiac surgery physicians is recommended to reduce complications. Intravenous antibiotics are first-line therapy with cardiac surgery being reserved for certain complications of IE and/or for clinical situations in which there is a high risk of complications. Timing of surgery for IE remains controversial and depends on a variety of clinical factors.

Epidemiology of infective endocarditis in a large Belgian non-referral hospital

Objectives:Guidelines for diagnosis of infective endocarditis are largely based upon epidemiological studies in referral hospitals. Referral bias, however, might impair the validity of guidelines in non-referral hospitals. Recent studies in non-referral care centres on infective endocarditis are sparse. We conducted a retrospective epidemiological study on infective endocarditis in a large non-referral hospital in a Belgian city (Kortrijk).Methods:The medical record system was searched for all cases tagged with a putative diagnosis of infective endocarditis in the period 2003–2010. The cases that fulfilled the modified Duke criteria for probable or definite infective endocarditis were included.Results:Compared to referral centres, an older population with infective endocarditis, and fewer predisposing cardiac factors and catheter-related infective endocarditis is seen in our population. Our patients have fewer prosthetic valve endocarditis as well as fewer staphylococcal endocarditis. Our patients undergo less surgery, although mortality rate seems to be highly comparable with referral centres, with nosocomial infective endocarditis as an independent predictor of mortality.Conclusion:The present study suggests that characteristics of infective endocarditis as well as associative factors might differ among non-referral hospitals and referral hospitals.

Nosocomial infective endocarditis in a renal transplant patient: culprit central venous line

Nosocomial infective endocarditis (IE) is a relatively uncommon but, a serious complication affecting critically ill hospitalized patients who are frequently exposed to life-saving invasive procedures. Immunosuppressive treatment in solid organ transplant recipients predisposes to infections, nevertheless, nonspecific symptoms of IE, such as fever, lassitude, weight loss, and signs of inflammation may often be misinterpreted as acute rejection episode or a common urinary tract infection. The case reported here was a recent renal transplant with methicillin-resistant Staphylococcus aureus IE. We believe the diagnoses of IE in her were missed at her first presentation due to her non-specific symptoms and lack of echocardiography and blood culture results. Septic procedure at insertion of central venous catheter (CVC) in the Intensive Care Unit with trauma to tricuspid valve (TV) at the time of CVC insertion was a possible source of infection for IE. The patient was managed effectively with intravenous antibiotics in spite of having hanging pedunculated vegetation on TV.

Preoperative Increasing C-reactive Protein Affects the Outcome for Active Infective Endocarditis

This study aimed to determine if preoperative time course changes in serum C-reactive protein (CRP) levels can predict clinical outcome of surgical intervention for active infective endocarditis. Surgically treated patients (n = 109) with active infective endocarditis were reviewed retrospectively. We divided the patients into 2 subgroups according to preoperative transition of increasing or decreasing serum CRP levels, and performed a comparative study. The increasing CRP group included 29 patients and the decreasing CRP group included 80 patients. There were more patients with methicillin-resistant Staphylococcus aureus and New York Heart Association functional class IV in the increasing CRP group. Hospital mortality was significantly higher in the increasing CRP group (34.5%) than that in the decreasing CRP group (5.0%) (p <0.05). In multivariate analysis, 3 significant risk factors of surgical outcome were identified: a tendency for increasing preoperative CRP levels (odds ratio [OR]: 18.15, 95% confidence interval [CI]: 1.03-320.78), nosocomial infective endocarditis (OR: 18.73, 95% CI: 1.57-223.60), and dialysis (OR: 1025.46, 95% CI: 2.89-363587.12). The outcome of operations for patients with increasing preoperative CRP levels is poor. For treatment of active infective endocarditis, a better operative result is expected when preoperative CRP levels are decreasing.

Infective endocarditis in congenital heart disease: a frequent community-acquired complication

Infective endocarditis (IE) is a severe complication in patients with congenital heart disease (CHD). Epidemiology, etiology, and outcome in this group are different to those of patients with acquired heart disease. We reviewed all cases of proven and probable IE (Duke's criteria) diagnosed in our center during the last two decades. We observed 45 cases of IE in patients with CHD (age range 8 months to 35 years); these represented 5.5 % of all the episodes of IE in our institution during the study period. The most frequent CHD were ventricular septal defect (31 %), tetralogy of Fallot (19 %), and atrioventricular septal defect (11 %). Twenty cases of IE (44 %) were recorded in patients with non-corrected native-valve CHD. Of the 24 patients with prosthetic-valve IE, post-operative acquisition during the first 6 months was confirmed in 11 patients (range 4-110 days). IE was community-acquired in 62 % of cases. Streptococcus spp. were the most frequent etiologic agents (33 %), followed by Staphylococcus spp. (32 %). Surgery was required to treat IE in 47 % of patients (52 % in prosthetic-valve IE and 41 % in native-valve IE, p = ns). In comparison to native-valve IE, prosthetic-valve IE was significantly more nosocomial-acquired (61 vs. 14 %, p = 0.002), presented a higher heart failure rate at diagnosis (39 vs. 9 %, p = 0.035), and developed more breakthrough bacteremia episodes (19 vs. 0 %, p = 0.048). Global mortality was 24 % (75 % in patients with prosthetic-valve IE who required surgery and 0 % in patients with native-valve IE who required surgery, p = 0.001). Multivariate analysis excluding breakthrough bacteremia (100 % mortality in this condition) confirmed that nosocomial IE [odds ratio (OR), 23.7; 95 % confidence interval (CI), 2.3-239.9] and the presence of heart failure at diagnosis of IE (OR, 25.9; 95 % CI, 2.5-269.6) were independent factors associated with mortality. Half of all cases of IE in patients with CHD occurred in patients with non-corrected native-valve CHD and two-thirds were community-acquired. Streptococcus spp. were the most frequent etiological agents. Patients with prosthetic-valve IE present a worse outcome, especially those requiring surgery. Breakthrough bacteremia, nosocomial IE, and heart failure are independent factors of mortality in patients with CHD presenting IE.

Epidemiology, characteristics, and outcome of infective endocarditis in Italy: the Italian Study on Endocarditis

The characteristics of patients with infective endocarditis (IE) vary significantly by region of the world. The aim of this study was to evaluate the contemporary epidemiology, characteristics, and outcome of IE in a large, nationwide cohort of Italian patients. We conducted a prospective, observational study at 24 medical centers in Italy, including all the consecutive patients with a definite or possible diagnosis of IE (modified Duke criteria) admitted from January 2004 through December 2009. A number of clinical variables were collected through an electronic case report form and analyzed to comprehensively delineate the features of IE. We report the data on patients with definite IE. A total of 1,082 patients with definite IE were included. Of these, 753 (69.6%) patients had infection on a native valve, 277 (25.6%) on a prosthetic valve, and 52 (4.8%) on an implantable electronic device. Overall, community-acquired (69.2%) was more common than nosocomial (6.2%) or non-nosocomial (24.6%) health care-associated IE. Staphylococcus aureus was the most common pathogen (22.0%). In-hospital mortality was 15.1%. From the multivariate analysis, congestive heart failure (CHF), stroke, prosthetic valve infection, S. aureus, and health care-associated acquisition were independently associated with increased in-hospital mortality, while surgery was associated with decreased mortality. The current mortality of IE remains high, and is mainly due to its complications, such as CHF and stroke.

Pediatric Infective Endocarditis Over the Last 30 Years: Thromboembolic Complications and Associations of Valve Vegetation and Heart Failure with Increased Mortality

AbstractAbstract 4223 Background:Pediatric infective endocarditis (IE) continues to be a condition associated with high morbidity and mortality. Contributing factors for IE-related morbidity include thromboembolic complications (TEC) (cerebrovascular events (CVE): acute ischemic stroke (AIS); non-CVEs: arterial/venous TEC outside of the central nervous system). Conversely, reported mortality risk factors include age, gender, vegetation size, and TEC. Objectives:To describe the experience of a single center tertiary pediatric hospital including patients diagnosed and treated with IE over the last three decades. Methods:A retrospective chart review of pediatric patients with definite IE by the Dukes Criteria admitted to the Hospital for Sick Children between January 1978 and January 2008 was conducted. Data distribution was divided into periods I (PI) (1978-1989), PII (1990-1999), and PIII (2000-2008). Thrombotic events were included only if radiologically proven, concomitantly and/or after IE confirmation; infectious etiology was accepted only by positive blood cultures; and heart failure was defined by clinical criteria. Descriptive statistics including percentages and means were calculated; categorical correlations used Chi-square statistics; survival analysis included Kaplan Meier analysis; p values<0.05 was considered statistically significant. Results:113 patients (pts) aged 0 to 18 years were included [mean: 3.6 yrs; females: 46 pts (41%)]. Congenital heart defects (CHD) were present in 95 pts (84%); cyanotic CHD in 33/95 (35%). In 64 pts (57%), 67 cardiac vegetations were found by echocardiogram [mitral (19%), aortic (18%), tricuspid valve (16%); multiple vegetations: 24/67 (36%)]; aneurysms occurred in 6 pts (5%). Large vegetations (≥1 cm) developed in 32 pts (27%). Only CHD (p=0.04), but not age, gender, or organism correlated with vegetation development. Overall, community acquired IE (CA-IE) was seen in 69/113 pts (61%), caused mostly by S. viridans; nosocomial and postoperative IE was caused mostly by S. aureus (54% vs. 27%; p<0.05), showing significantly higher mortality (27% vs. 7%; p<0.05). Period III showed the highest rate of older pts (p<0.001), CA-IE (p=0.04), vegetations (p=0.01), and TEC (p=0.01), but not of surgical interventions; yet, mortality was comparable in all periods (p=0.98).Fourty-one pts developed 44 TEC (40%), the presenting feature in 14 pts (12%). 22 pts (19%) were diagnosed with CVE (18 AIS; 4 cerebral mycotic aneurysms); 23 pts (20%) had non-CVE. Only older age (>3yrs) correlated with either CVE (p=0.04), or non-CVE (p=0.004). Conversely, TEC (p=0.06), AIS, or non-CVE did not predict mortality (p=0.5). Anticoagulation usage included: a) heparin/low molecular weight (3 pts), warfarin (8 pts), and antiplatelet therapy (22 pts); no major bleeding occurred. Overall, 5-yr mortality rate was 15%. Risk factors for mortality by univariate analysis included vegetations (p=0.001), vegetation size (p=0.01), and heart failure (p<0.001), of which vegetations (OR: 11.1, 95%CI: 1.5–88; p=0.005) and heart failure (OR: 145.0, 95%CI: 18–1221; p<0.0001) were confirmed by multivariate logistic regression. Overall survival at 1 month from IE diagnosis in patients without or with heart failure was approximately 92% and 75%, respectively (p<0.0001). Conclusions:Our single tertiary centre study reports a growing, high incidence rate of TEC in children with confirmed IE over the last three decades. Children >3yrs had a higher risk to develop any type of TEC; however, neither CVE nor non-CVE were associated with an increased mortality. While no major bleeding events occurred in pts treated with anticoagulants, there are limitations to comment on its safety in this condition. Mortality rate remained stable over time; heart failure and the presence of vegetations significantly increased the risk for death. Disclosures:No relevant conflicts of interest to declare.

Nosocomial infective endocarditis: should the definition be extended to 6 months after discharge

Because the microbiology and patient population of infective endocarditis (IE) have evolved, the traditional definition of nosocomial IE may require revision. The question of whether this definition should be extended to 6 months after discharge was explored, and a high rate of episodes with nosocomial pathogens (coagulase-negative staphylococci) and a low rate of episodes with community pathogens (streptococci) in the extended nosocomial group were found. Therefore, modification of the traditional definition is proposed, distinguishing between early (as traditionally described) and late nosocomial IE (IE in association with a significant invasive procedure performed during a hospitalization between 8 weeks and 6 months before the onset of symptoms).

Nosocomial vs. community-acquired infective endocarditis in Greece: changing epidemiological profile and mortality risk

Current epidemiological trends of infective endocarditis (IE) in Greece were investigated via a prospective cohort study of all cases of IE that fulfilled the Duke criteria during 2000-2004 in 14 tertiary and six general hospitals in the metropolitan area of Athens. Demographics, clinical data and outcome were compared for nosocomial IE (NIE) and community-acquired IE (CIE). NIE accounted for 42 (21.5%) and CIE for 153 (78.5%) of 195 cases. Intravenous drug use was associated exclusively with CIE, while co-morbidities (cardiovascular disease, diabetes mellitus, chronic renal failure requiring haemodialysis and malignancies) were more frequent in the NIE group (p <0.05). Prosthetic valve endocarditis (PVE) predominated in the NIE group (p 0.006), and >50% of NIE cases had a history of vascular intervention. Coagulase-negative staphylococci and enterococci were more frequent in cases of NIE than in cases of CIE (26.2% vs. 5.2%, p <0.01, and 30.9% vs. 16.3%, p 0.05, respectively). Enterococci accounted for 19.5% of total IE cases and were the leading cause of NIE. Staphylococcus aureus IE was hospital-acquired in only 11.9% of cases. In-hospital mortality was higher for NIE than for CIE (39.5% vs. 18.6%, p 0.02). Cardiac failure (New York Heart Association grade III-IV; OR 13.3, 95% CI 4.9-36.1, p <0.001) and prosthetic valve endocarditis (OR 3.7, 95% CI 1.3-10.6, p 0.01) were the most important predictors of mortality.