Risk Of Infective Endocarditis Research Articles

Infective endocarditis after transcatheter approach versus surgical pulmonary valve replacement: A meta-analysis.

Background In this meta-analysis, we aimed to assess the risk of infective endocarditis in transcatheter versus surgical pulmonary valve replacement patients. Methods We systematically searched PubMed, Cochrane, EMBASE, Scopus, and Web of Science for the studies that reported the event rate of infective endocarditis in both transcatheter and surgical pulmonary valve replacement between December 2012 and December 2021. Random-effects model was used in the meta-analysis. Results Fifteen comparison groups with 4,706 patients were included. The mean follow-up was 38.5±3.7 months. Patients with transcatheter pulmonary valve replacement had a higher risk of infective endocarditis than patients receiving surgically replaced valves (OR 2.68, 95% CI: 1.83-3.93, p<0.00001). The calculated absolute risk difference was 0.03 (95% CI: 0.01-0.05), indicating that if 1,000 patients received a surgical valve replacement, 30 cases of infective endocarditis would be prevented. A meta-regression of follow-up time on the incidence of infective endocarditis was not statistically significant (p=0.753). Conclusion Although transcatheter pulmonary valve replacement is a feasible alternative to surgical replacement in severe right ventricular outflow tract dysfunction, the higher incidence of infective endocarditis in transcatheter replacement remains a significant concern. Regarding this analysis, surgical treatment of right ventricular outflow tract dysfunction is still a viable option in patients with prohibitive risk.

Epidemiology, burden, and attributable risks of infective endocarditis in Iran and its provinces: From 1990 to 2019

BackgroundEndocarditis is a potentially life-threatening infectious disease associated with significant morbidity and mortality and an escalating incidence in recent decades. In this study, as a part of the global burden of disease (GBD) 2019 study, we intend to report endocarditis burden in Iran at national and provincial levels from 1990 to 2019. MethodThis study was conducted using GBD 2019 study data on endocarditis from 1990 to 2019. We gathered incidence, prevalence, disability-adjusted life years (DALYs), and mortality rates in Iran and its 31 provinces by sex and age groups as epidemiological indices for endocarditis burden. Further decomposition analysis was also performed to delineate the endocarditis new cases trend. ResultsOn the country scale, age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), age-standardized mortality rate (ASMR), and age-standardized DALYs rate were (16.5 (95% uncertainty interval 13.7 to 19.8), 3.4 (2.9 to 4.1), 0.6 (0.5 to 0.9), and 14.4 (12.0 to 21.1) in 2019, respectively. Decomposition analysis showed that only 59.2% of the overall new cases increase (114.1%) was caused by the incidence rate change. All estimated age-standardized rates were higher in men in 1990 and 2019 with a ratio of 1.1–1.5. ConclusionThe ASIR and ASPR of endocarditis increased, and the ASMR and age-standardized DALYs rate declined over the past 30 years in Iran, nearly all the provinces followed the same pattern with North Khorasan having the Highest ASIR, ASPR, ASMR, and DALYs rates in both years. High systolic blood pressure (SBP) had the greatest attributed burden among risk factors.

Bacteraemia and infective endocarditis with Streptococcus bovis-Streptococcus equinus-complex: a retrospective cohort study

Background Streptococcus bovis/equinus complex (SBSEC) comprise several species and subspecies and is a common cause of infective endocarditis (IE). S. gallolyticus subsp. gallolyticus (Sg gallolyticus) accounts for a majority of SBSEC IE, but the risk of IE for other subspecies is largely unknown. We aimed to investigate the clinical presentation of bacteraemia, and proportion of patients with IE in bacteraemia with the most common subspecies. Methods A retrospective cohort study of SBSEC-bacteraemia identified in clinical laboratory databases, in Skåne Region, Sweden, 2003–2018. Bacteraemia with Sg gallolyticus, S. gallolyticus subsp. pasteurianus (Sg pasteurianus), S. lutetiensis and S. infantarius subsp. infantarius (Si infantarius) were included. Subspecies was identified by whole genome sequencing. Medical charts were reviewed according to a predetermined protocol, IE was defined by the criteria from European Society of Cardiology. Results In total, 210 episodes of SBSEC-bacteraemia were included. Definite IE was identified in 28/210 (13%) episodes. Of these, 7/28 (25%) were prosthetic valve-IE, 1/28 (4%) related to a cardiovascular implantable electronic device and 10/28 (36%) required heart valve surgery. The proportions of IE among different subspecies were: Sg gallolyticus 17/52 (33%), Si infantarius 5/31 (16%), Sg pasteurianus 4/83 (5%) and S. lutetiensis 2/44 (5%) (p < 0.001). Sg pasteurianus and S. lutetiensis were more often associated with intra-abdominal- and polymicrobial infection. Conclusion The proportion of IE in SBSEC-bacteraemia varies substantially depending on subspecies. Echocardiography should always be considered in bacteraemia with Sg gallolyticus and Si infantarius, and can sometimes be omitted in bacteraemia with Sg pasteurianus and S. lutetiensis.

Risk of infective endocarditis associated with invasive dental procedures in patients with cardiac rhythm devices.

The incidence of infective endocarditis related to cardiac implantable electronic devices (CIEDs) has gradually increased. The risk associated with dental procedures in patients with CIED implantation and the need for prevention of infective endocarditis remain unclear. The present study investigated the incidence and risk of infective endocarditis associated with invasive dental procedures in patients with CIEDs. We analysed a nationwide population-based cohort of patients with CIEDs who underwent dental procedures. We performed a self-controlled case series analysis and evaluated the incidence rate ratio of infective endocarditis 3 months after dental procedures. Of a total of 62 019 patients who underwent CIED implantation, 32 536 patients underwent at least one dental procedure during follow-up, and the mean number of dental procedures was 3.4 per patient. They were 152 infections with an incidence of 445 per 100 000 person-years in the dental procedure period and 500 events at an incidence of 255 per 100 000 person-years in the non-dental procedure period. The CIED-related infective endocarditis in the dental procedure period occurred significantly more frequently than during non-dental procedure periods (odds ratio, 1.75; 95% confidence interval, 1.48-2.05; P < 0.001). The mean time interval from dental procedure to infective endocarditis was 59.6 ± 47.3 days. Invasive dental procedures are associated with an increased risk of infective endocarditis in those who underwent CIED implantation. Appropriate preventive therapy might be needed in these patients.

Ticagrelor prevents infective endocarditis by mitigating Staphylococcus aureus virulence

Infective endocarditis (IE) is a deadly disease mainly caused by the gram-positive and highly virulent bacteria Staphylococcus aureus (SA). Due to lack of efficacy of current antibiotic therapy, there is an urgent need to discover new strategies that could prevent this disease. To assess the ability of the antiplatelet drug ticagrelor, which also displays antibacterial activity against gram-positive bacteria, to prevent SAIE. We used a mouse model of infective endocarditis induced by a SAIE clinical isolate. Ticagrelor was administered orally at a conventional dosage (3 mg/kg, single dose) prior to infection and local histamine infusion on the aortic valve. Infected vegetation presence was determined by Gram staining on heart sections after three days. Antibacterial effect of ticagrelor at dosages equivalent to plasma levels achieved in patients (0.75–1.25 μg/mL) was assessed in vitro in human blood. Ticagrelor significantly prevented the formation of infected vegetation, with IE in only 14.3% of ticagrelor-treated mice ( n = 21) compared to 52.3% of vehicle-treated mice ( n = 37). Ex vivo ADP-induced platelet aggregation assays confirmed rapid reversibility of antiplatelet activity (4 hours), which made it unlikely that solely the antiplatelet effect would explain IE prevention by ticagrelor. Bacterial survival in blood was not diminished three days post-infection. We therefore assessed whether ticagrelor could affect bacterial virulence. We found that growing SA in the presence of 1.25 μg/mL ticagrelor inhibited a-toxin RNA expression and protein secretion, which was corroborated with drastically reduced hemolysis and platelet aggregation induced by bacterial supernatants. Ticagrelor-treated bacteria could no longer adhered to fibrinogen, and in whole blood perfusion experiments, flow-dependent bacterial adhesion on activated endothelial cells was severely impaired. Our study demonstrates the unprecedented ability of ticagrelor to prevent IE by a novel mechanism of directly mitigating bacterial virulence. Hence, clinical trials using ticagrelor as adjunct therapy to antibiotics in patients at risk for IE are warranted.

Clinical Characteristics and Risk Factors for in-Hospital Mortality in 240 Cases of Infective Endocarditis in a Tertiary Hospital in China: A Retrospective Study.

PurposeThis study aimed (i) to investigate the clinical characteristics and risk factors related to in-hospital mortality in patients with infective endocarditis (IE) and (ii) to compare the differences in three age groups.MethodsA total of 240 IE cases diagnosed using the modified Duke criteria between January 2016 and December 2019 were included and retrospectively studied. Patients were stratified into three age groups: < 50 y, 50–65 y, and > 65 y.ResultsThe mean age of the patients was 51 ± 14 y, and 154 patients (64.2%) were male. In addition, 136 (56.7%) patients with IE had no previous cardiac disease. Congenital heart disease (CHD, 21.3%) was the most common underlying heart disease, followed by rheumatic heart disease (RHD, 8.8%). Streptococcus was found in 55 (22.9%) patients and was the most common causative pathogen, comprising 52.9% of all positive blood cultures. Echocardiography showed the presence of vegetations in 88.3% of cases and the predominant involvement of the left heart valves. Fever and cardiac murmur were the most frequent presentations, with no significant differences among age groups. Compared with younger patients, elderly patients had a lower operation rate and higher in-hospital mortality. The independent risk factors of in-hospital mortality were age > 65 y, intracranial infection, splenic embolization, cerebral hemorrhage, NYHA class III–IV, and prosthetic valve infection.ConclusionCHD replaces RHD as the most common underlying heart disease in IE patients. Patients without previous cardiac disease are at increased risk of IE. Streptococcus is still the primary causative pathogen of IE. Elderly patients present with more comorbidities and complications, in addition to a more severe prognosis than younger patients. Age older than 65 y, intracranial infection, splenic embolization, cerebral hemorrhage, NYHA class III–IV, and prosthetic valve infection showed poorer in-hospital outcomes.

Infection and infective endocarditis after cardiac implantable electronic device implantation: a contemporary nationwide cohort study

Abstract Funding Acknowledgements Type of funding sources: None. Aims To determine the contemporary incidence and risk factors of infection and infective endocarditis (IE) following implantation of a first-time, permanent, cardiac implantable electronic device (CIED). Methods This French longitudinal cohort study was based on the national hospitalization database covering hospital care from for the entire population. All adults (age ≥18 years) hospitalized in French hospitals from January 1, 2010 to December 31, 2019, who underwent a de novo permanent pacemaker (PM) or implantable cardioverter defibrillator (ICD) implantation were identified together with the occurrence of post-implantation infection and IE-events during follow-up. Results In total 688,007 CIED patients with de novo implants were identified (single-chamber pacemaker 18.8%, dual-chamber pacemaker 64.9%, cardiac resynchronization therapy [CRT]pacemaker 3.2%, single-chamber ICD 4.3%, dual-chamber ICD 3.4%, CRT ICD 5.5%). Follow-up was 2.6±2.6 years (median 1.9, IQR 0.2-4.3 years) and total follow-up time was 1,788,166person-years (PYs). There were 9,804 patients with CIED-related infection during follow-up (incidence rate 5.48 per 1000 patient.year) among whom 2,658 had IE (incidence rate 1.49 per 1000 patient.year). The incidence rate (per 1000 PYs) of CIED-related infection and IE in the different subgroups of patients with pacemakers and ICD (single-chamber, dual-chamber, CRT) are in table 1. Incidence rates were higher in patients with an ICD than in those with a pacemaker, and higher in those with CRT. Incidence rates of CIED-related infection and IE were not different in single-chamber vs dual-chamber CIEDs(table 1). In multivariable analysis, ICD (vs pacemaker, HR: 1.59; 95% CI 1.40-1.80) and CRT (vs no CRT, HR: 1.21; 95% CI: 1.07-1.37) were independent risk factors for CIED-related infection. Dual-chamber pacemakers were not associated with a higher risk of CIED-related infection than single-chamber pacemakers. Similarly, dual-chamber ICDs were not associated with a higher risk of CIED-related infection than single-chamber ICDs (table). There were similar findings when analysing the risk of IE during FU. ICD (vs pacemaker, HR: 1.31; 95% CI 1.23-1.40) and CRT (vs no CRT, HR: 1.24; 95% CI: 1.16-1.32) were independent risk factors for IE. Dual-chamber pacemakers were not associated with a higher risk of IE than single-chamber pacemakers and dual-chamber ICDs were not associated with a higher risk of IE than single-chamber ICDs (table). Results were similar when one considered separately the periods 2010-2014 and 2015-2019 Conclusion The risk of CIED-related infection and IE was significantly higher in patients with ICDs than in those with pacemakers and significantly higher with CRT than with no CRT. By contrast, there was no statistical difference in the risk of CIED-related infection and IE in patients with single-chamber or dual-chamber CIEDs in this contemporary analysis at a nationwide level.

Cardiac surgery in cardiac implantable electronic device patients and risk of device infections: a nationwide nested case-control study

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Karen Elise Jensen’s Foundation Background Cardiac surgery in patients with cardiac implantable electronic devices (CIEDs) has been associated with a higher risk of infective endocarditis, but how it influences risk of CIED-specific infections is not known. Purpose To examine risk of systemic CIED infections after cardiac surgery in patients with CIEDs. Methods Based on data obtained from Danish administrative registries and the Danish Pacemaker and ICD Register, we conducted a case-control study nested within a nationwide cohort of patients who underwent a de novo CIED implantation in Denmark between 1998-2017. Patients entered the study at six months after implantation. We defined cases as incident systemic CIED infections resulting in device system extraction. Controls were sampled 1:100 on age, sex and follow-up time using risk set sampling. Exposure was defined as coronary artery bypass graft (CABG)-, or cardiac heart valve replacement- or repair surgery. Results From a study cohort comprising 67,621 patients, we identified 170 cases and 16,966 controls. In the minimally adjusted model, the incidence rate ratio (IRR) for systemic CIED infection was 6.4 (95% confidence interval (CI) 3.9-17.1) with cardiac surgery, and after confounder adjustment, 7.0 (95% CI 4.1-11.9). IRRs were higher when exposure was restricted to heart valve replacement surgery (adjusted IRR (aIRR) 9.7, 95% CI 5.2-17.8), and when limiting our exposure time window to one year (aIRR 12.7, 95% CI 5.8-27.8). Conclusion Cardiac surgery in patients with de novo CIEDs was associated with a high risk of systemic CIED infections. Highest risk was observed after heart valve replacement surgery, and within the first year of surgery.

Prevention of Infective Endocarditis of Oral Origin in Children: A Call for Pediatric Dentists–Pediatric Cardiologists’ Collaboration in Egypt

To assess knowledge and practices of some Egyptian pediatric dentists and pediatric cardiologists/cardiac surgeons regarding prevention of infective endocarditis (IE) from oral origin in children. Pediatric dentists or pediatric cardiologists/cardiac surgeons having their practice in Egypt were conveniently selected. An online questionnaire was constructed for each specialty practitioner in English using a web-based platform. Each survey tool collected data about demographics, knowledge, and practices concerning the prevention of IE of oral origin. Surveys were disseminated to potential respondents using direct messaging or posting surveys' links on high-traffic areas (blogs, groups, or pages) of commonly known social media platforms. Two-hundred and thirty-nine pediatric dentists and 71 pediatric cardiologists/cardiac surgeons' responses were included in analysis. Some shortage in oral health knowledge and deviations in management protocol from known guidelines were evident in cardiologists' responses, whereas 66.2 and 64.8% reported encountering IE of oral origin or canceling a cardiac surgery due to oral infection, respectively. Most pediatric dentists (65.7%) rely on physician referral before managing children at risk of IE despite following recognized guidelines for IE prevention which may reflect difficulty in understanding such guidelines. Ninety percent of children with heart diseases visit a dentist due to oral complaint and not for checkup. Identification of disparities and pitfalls in management of children with heart diseases, if appropriately addressed by pediatric dentists and cardiologists, may reduce the risk of IE from an oral origin. Health education of both specialists and development of national guidelines based on national epidemiology and clinical experience of cardiologists are strongly needed to decrease oral disease burden, allow for a consensus of patient management, and minimize the need for cross-referral, thus facilitating dental management without undue delays.

Cardiac surgery in patients with cardiac implantable electronic devices and risk of device infections: a nationwide nested case-control study.

Cardiac surgery in patients with cardiac implantable electronic devices (CIEDs) has been associated with a higher risk of infective endocarditis, but how it influences risk of CIED-specific infections is not known. Our aim was to examine risk of systemic CIED infections after cardiac surgery in patients with CIEDs. Based on data obtained from Danish administrative registries and the Danish Pacemaker and ICD Register, we conducted a case-control study nested within a nationwide cohort of patients who underwent a de novo CIED implantation in Denmark between 1998 and 2017. We defined cases as incident systemic CIED infections resulting in device system extraction. Controls were sampled 1:100 on time, age, sex and device type using risk set sampling. Exposure was defined as coronary artery bypass graft, or cardiac heart valve replacement or repair surgery. From a study cohort comprising 67,621 patients, we identified 170 cases and 16,788 controls. In the minimally adjusted model, the incidence rate ratio (IRR) for systemic CIED infection was 6.4 (95% confidence interval (CI) 3.8-10.7) with cardiac surgery, and after additional confounder adjustment, 5.4 (95% CI 3.2-9.2). IRRs were higher with restriction to heart valve replacement surgery (adjusted IRR 7.5, 95% CI 4.0-16.6), and when limiting our exposure time window to one year (adjusted IRR 10.1, 95% CI 4.5-22.3). Cardiac surgery in patients with de novo CIEDs was associated with a high risk of systemic CIED infections. Highest risk was observed after heart valve replacement surgery and within the first year of surgery.

Infective endocarditis following invasive dental procedures: IDEA case-crossover study

Infective endocarditis is a heart infection with a first-year mortality rate of ≈ 30%. It has long been thought that infective endocarditis is causally associated with bloodstream seeding with oral bacteria in ≈ 40-45% of cases. This theorem led guideline committees to recommend that individuals at increased risk of infective endocarditis should receive antibiotic prophylaxis before undergoing invasive dental procedures. However, to the best of our knowledge, there has never been a clinical trial to prove the efficacy of antibiotic prophylaxis and there is no good-quality evidence to link invasive dental procedures with infective endocarditis. Many contend that oral bacteria-related infective endocarditis is more likely to result from daily activities (e.g. tooth brushing, flossing and chewing), particularly in those with poor oral hygiene. The aim of this study was to determine if there is a temporal association between invasive dental procedures and subsequent infective endocarditis, particularly in those at high risk of infective endocarditis. This was a self-controlled, case-crossover design study comparing the number of invasive dental procedures in the 3 months immediately before an infective endocarditis-related hospital admission with that in the preceding 12-month control period. The study took place in the English NHS. All individuals admitted to hospital with infective endocarditis between 1 April 2010 and 31 March 2016 were eligible to participate. This was an observational study; therefore, there was no intervention. The outcome measure was the number of invasive and non-invasive dental procedures in the months before infective endocarditis-related hospital admission. NHS Digital provided infective endocarditis-related hospital admissions data and dental procedure data were obtained from the NHS Business Services Authority. The incidence rate of invasive dental procedures decreased in the 3 months before infective endocarditis-related hospital admission (incidence rate ratio 1.34, 95% confidence interval 1.13 to 1.58). Further analysis showed that this was due to loss of dental procedure data in the 2-3 weeks before any infective endocarditis-related hospital admission. We found that urgent hospital admissions were a common cause of incomplete courses of dental treatment and, because there is no requirement to record dental procedure data for incomplete courses, this resulted in a significant loss of dental procedure data in the 2-3 weeks before infective endocarditis-related hospital admissions. The data set was also reduced because of the NHS Business Services Authority's 10-year data destruction policy, reducing the power of the study. The main consequence was a loss of dental procedure data in the critical 3-month case period of the case-crossover analysis (immediately before infective endocarditis-related hospital admission), which did not occur in earlier control periods. Part of the decline in the rate of invasive dental procedures may also be the result of the onset of illness prior to infective endocarditis-related hospital admission, and part may be due to other undefined causes. The loss of dental procedure data in the critical case period immediately before infective endocarditis-related hospital admission makes interpretation of the data difficult and raises uncertainty over any conclusions that can be drawn from this study. We suggest repeating this study elsewhere using data that are unafflicted by loss of dental procedure data in the critical case period. This trial is registered as ISRCTN11684416. This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 28. See the NIHR Journals Library website for further project information.

Clinical prediction scores and the utility of time to blood culture positivity in stratifying the risk of infective endocarditis in Staphylococcus aureus bacteraemia.

Infective endocarditis (IE) complicates up to a quarter of Staphylococcus aureus bacteraemia (SAB) cases. Risk scores predict IE complicating SAB but have undergone limited external validation, especially in community-acquired infections and those who use IV drugs. Addition of the time to positive culture (TTP) may provide incremental risk prognostication. To externally validate risk scores for predicting IE in SAB and assess the incremental value of TTP. The modified Duke score was calculated for adults hospitalized with SAB at a major tertiary institution. All patients underwent echocardiography. Sensitivity and specificity of the risk scores for predicting IE were calculated, and the incremental value of TTP was assessed. One hundred and six cases were analysed and 18 (17%) met definite IE criteria. The optimal TTP to predict IE was 11.5 h (sensitivity 88.9%; specificity 71.6%). The sensitivity of VIRSTA and PREDICT (Predicting risk of endocarditis using a clinical tool) were similar (94.4% for both) and higher than POSITIVE (Prediction Of Staphylococcus aureus Infective endocarditis Time to positivity, IV drug use, Vascular phenomena, pre-Existing heart condition; 77.8%). The receiver-operator characteristic AUCs were VIRSTA 0.83, PREDICT 0.75, POSITIVE 0.89 and TTP 0.85. Adding TTP to VIRSTA (i.e. VIRSTA+) resulted in the highest AUC (0.90), sensitivity (100%) and negative predictive value (100%), albeit with a low specificity (33%). The VIRSTA and POSITIVE scores were the strongest predictors for IE complicating SAB. The addition of TTP to VIRSTA (VIRSTA+) significantly improved discriminatory value and may be safely used to rationalize echocardiography strategies.

Outcomes of leadless pacemaker implantation in patients with mechanical heart valves.

Device infections constitute a major complication of transvenous pacemakers. Mechanical heart valves (MHV) increase the risk of infective endocarditis (IE) and pacemaker infection, requiring lifelong vitamin K-antagonists (VKA), which may affect patient management. Leadless pacemakers (LP) are associated with low infection rates, posing an attractive option in MHV patients requiring permanent pacing. This study describes outcomes following LP implantation in patients with MHV. This is a multicenter, observational, retrospective study including consecutive patients implanted with an LP at 5 centers between June 2015 and January 2020. Procedural outcomes, antithrombotic management, complications, performance during follow-up and episodes of bacteremia and IE were compared between patients with and without an MHV (MHV and non-MHV groups). Four hundred fifty-nine patients were included (74 in the MHV group, 16.1%, and 385 in the non-MHV group, 83.9%). Procedural outcomes and acute electrical performance were comparable between groups. Vascular complications and cardiac perforation occurred in 2.7 versus 2.3% (p = 1) and 0% versus 0.8% (p = 1) in the MHV group and non-MHV group. One case of IE occurred in the MHV group and 2 in the non-MHV group. In MHV patients, uninterrupted VKA was used in 83.8%, whereas 16.2% were heparin-bridged. Vascular complication or tamponade occurred in 1 (8.3%) MHV heparin-bridged patient versus 1 (1.6%) MHV uninterrupted VKA patient (p = .3). LP implantation outcomes in MHV patients are comparable to the general LP population. Device-related infections are rare following LP implantation, including in patients with MHV. In the MHV group, periprocedural anticoagulation management was not associated with significantly different rates of tamponade or vascular complication.

Infective endocarditis in a cohort of adult CHD patients.

CHD increases the risk of infective endocarditis due to the substrate of prosthetic materials and residual lesions. However, lesion-specific and mortality risks data are lacking. We sought to analyse clinical course and mortality of infective endocarditis in a cohort of adult CHD. Retrospective analysis of all cases of proven and probable infective endocarditis (Duke's criteria) followed in our adult CHD clinic between 1970 and August, 2021. Epidemiological, clinical and imaging data were analysed. Predictors of surgical treatment and mortality were assessed using regression analysis. During a mean follow-up of 15.8 ± 10.9 years, 96 patients had 105 infective endocarditis episodes, half with previous cardiac surgery (corrective or palliative). The most frequent diagnoses were: ventricular septal defect, bicuspid aortic valve, Tetralogy of Fallot and pulmonary atresia. The site of infection was identified by echocardiography in 82 episodes (91%), most frequently in aortic (n = 27), tricuspid (n = 15), and mitral (n = 13) valves. Blood cultures were positive in 79% of cases, being streptococci (n = 29) and staphylococci (n = 23) the predominant pathogens. Surgery was necessary in 40% and the in-hospital mortality was 10.5%, associated with heart failure (p < 0.001; OR 13.5) and a non-surgical approach (p = 0.003; OR 5.06). In an adult CHD cohort, infective endocarditis was more frequent in patients with ventricular septal defect and bicuspid aortic valves, which contradicts the current guidelines that excludes them from prophylaxis. Surgical treatment is often required and mortality remains substantial. Prevention of this serious complication should be one of the major tasks in the care of adults with CHD.

Unexpected Infective Endocarditis in Corrected Congenital Heart Disease: A Case Report

Objective: To describe patients with corrected Congenital Heart Disease (CHD) who experienced Infective Endocarditis (IE). Methods: Two cases of IE were observed in 2019. The first case involved a 36-year-old woman with previous percutaneous transcatheter perimembranous ventricular septal defect (VSD) closure four months before admission. Echocardiography showed vegetation at noncoronary cusps of the aortic valve. Patient received antibiotics for six weeks and underwent surgery for evacuation of vegetation and device, along with VSD closure with a cardiovascular patch (Gore-tex). The second case involved a 43-year-old woman with a history of surgical closure in secundum atrial septal defect (ASD) by pericardial patch two months before admission. Echocardiography showed vegetation at the tricuspid valve. Patient received antibiotics for four weeks and planned for surgery to evacuate vegetation. Results: IE is one of the major complications in CHD, whether uncorrected, treated, or corrected. The risk of IE increased with an invasive procedure. Post closure IE is rare. Poor dental hygiene and immunocompromised also increased patient's risk to be exposed to IE as shown in the first patient who had dental caries and the second patient who was on methylprednisolone for post-surgical pericardial effusion treatment. Conclusion: The risk of IE increases with invasive procedures in CHD patients. Although the incidence of IE is quite rare, its possibility should become of a serious concern among physicians.

Devising a pro forma for dental screening of patients before invasive cardiac surgery.

Certain types of invasive cardiac surgery can place patients at risk of developing infective endocarditis from dental pathology or dental treatment. University Hospital Bristol and Weston NHS Foundation Trust is the regional centre for cardiac surgery in the South West of the UK and is part of the South Wales and South West Congenital Heart Disease Network. As part of this network, the Special Care Dental Department within Bristol Dental Hospital provides dental screening for patients pending invasive cardiac surgery. These are conducted to identify dental pathology in individuals who will be at risk of infective endocarditis, so where possible, they are rendered dentally fit before their surgery.Presented is the information that led to the creation of a screening pro forma, for the dental assessment of patients before invasive cardiac surgery, suitable for use in primary or secondary care. This was produced following an audit, to ensure that along with identifying sources of dental pathology, the dental screening is also documenting the risk of dental pathology and modifiable risk factors. This enables tailored preventative advice which is important to help reduce a patient's lifetime risk of infective endocarditis from dental pathology. Other information used to help develop the pro forma taken from the audit, regional and national guidance is also discussed.

Infective Endocarditis Among High-risk Individuals Before and After the Cessation of Antibiotic Prophylaxis in Dentistry: A National Cohort Study.

BackgroundA few years after the publication of the British guidelines, national recommendations were published by the Swedish Medical Products Agency in October 2012, promoting the cessation of antibiotic prophylaxis in dentistry for the prevention of infective endocarditis (IE). The aim of this study was to evaluate whether the incidence of oral streptococcal IE increased among high-risk individuals after October 2012.MethodsThis nationwide cohort study included all adult individuals (>17 years) living in Sweden from January 2008 to January 2018, with a diagnose code or surgical procedure code indicating high risk of IE. Cox proportional hazard models were performed to calculate adjusted ratios of oral streptococcal IE before and after October 2012 between high-risk individuals and references.ResultsThis study found no increased incidence of oral streptococcal IE among high-risk individuals during the 5 years after the cessation, compared with before. Hazard rate ratios were 15.4 (95% confidence interval [CI]: 8.3–28.5) before and 20.7 (95% CI: 10.0–42.7) after October 2012 for prevalent high-risk individuals. Corresponding ratios for incident high-risk individuals were 66.8 (95% CI: 28.7–155.6) and 44.6 (95% CI: 22.9–86.9). Point estimates for interaction with time period were 1.4 (95% CI: .6–3.5) and 0.8 (95% CI: .5–1.3) for prevalent and incident high-risk individuals, respectively.ConclusionThe results suggest that the current Swedish recommendation not to administer antibiotic prophylaxis for the prevention of IE in dentistry has not led to an increased incidence of oral streptococcal IE among high-risk individuals.

A qualitative exploration of preventive dental advice for parents of children with congenital heart disease

Background/Aims Children with congenital heart disease are at an increased risk of developing oral disease, which can negatively impact their general health and increase the risk of infective endocarditis. This study explored the preventive oral health advice given to parents of children with congenital heart disease and any barriers that exist to the implementation of this advice. Methods Four semi-structured interviews were conducted with parents of children with congenital heart disease, which followed a topic guide that explored personal experiences of oral healthcare provision and the advice received. Interviews were audio recorded and transcribed verbatim. Thematic analysis was undertaken by one researcher, with themes reviewed by a second. Results Improving awareness of oral health was highlighted as being important to participants. The prioritisation of the child's heart condition was also discussed, and participants felt that there were opportunities to develop the multidisciplinary collaboration between dental and cardiac teams. The consistency of messages could also be enhanced, as health advice sometimes contradicted oral health guidance, which could unintentionally increase the child's risk of tooth decay. Conclusions Enhancing collaboration between the various disciplines involved in the care of children with congenital heart disease is needed to ensure that appropriate advice and support is given to parents regarding oral health.

Current Concepts in Prophylactic Antibiotics in Oral and Maxillofacial Surgery.

Antibiotic prophylaxis is the use of antibiotics in the perioperative period to prevent surgical site infections from local flora. Specific guidelines and criteria exist to prevent these infections while also practicing antimicrobial stewardship. Most dentoalveolar procedures do not require antibiotic prophylaxis. For nondentoalveolar procedures, the decision to provide antibiotic prophylaxis is based on involvement of the respiratory, oral, or pharyngeal mucosa. Special considerations exist for patients at high risk for infective endocarditis, patients with head and neck cancer, and temporomandibular joint replacement procedures. This article discusses indications for antibiotic prophylaxis during oral and maxillofacial surgical procedures.

The role of systemic diseases and local conditions as risk factors.

The role of systemic diseases and local conditions as risk factors.