Staphylococcal Prosthetic Valve Endocarditis Research Articles

Deconstructing the Dogma: Systematic Literature Review and Meta-analysis of Adjunctive Gentamicin and Rifampin in Staphylococcal Prosthetic Valve Endocarditis.

Based primarily on in vitro and animal models, with little data directly addressing patient outcomes, current guidelines recommend treating staphylococcal prosthetic valve endocarditis (PVE) with antibiotic combinations including gentamicin and rifampin. Here, we synthesize the clinical data on adjunctive rifampin and gentamicin in staphylococcal PVE. We conducted a systematic review and meta-analysis of PubMed- and Cochrane-indexed studies reporting outcomes of staphylococcal PVE treated with adjunctive rifampin, gentamicin, both agents, or neither (ie, glycopeptide or β-lactam monotherapy). We recorded outcomes including mortality, relapsed infection, length of stay, nephrotoxicity, hepatotoxicity, and important drug-drug interactions (DDIs). Four relevant studies were identified. Two studies (n = 117) suggested that adding gentamicin to rifampin-containing regimens did not reduce clinical failure (odds ratio [OR], 0.98 [95% confidence interval {CI}, .39-2.46]), and 2 studies (n = 201) suggested that adding rifampin to gentamicin-containing regimens did not reduce clinical failure (OR, 1.29 [95% CI, .71-2.33]). Neither gentamicin nor rifampin was associated with reduced infection relapse; 1 study found that rifampin treatment was associated with longer hospitalizations (mean, 31.3 vs 42.3 days; P < .001). Comparative safety outcomes were rarely reported, but 1 study found rifampin to be associated with hepatoxicity, nephrotoxicity, and DDIs, leading to treatment discontinuation in 31% of patients. The existing clinical data do not suggest a benefit of either adjunctive gentamicin or rifampin in staphylococcal PVE. Given that other studies also suggest these agents add nephrotoxicity, hepatoxicity, and risk of DDIs without benefit in staphylococcal endovascular infections, we suggest that recommendations for gentamicin and rifampin in PVE be downgraded and primarily be used within the context of clinical trials.

Conundrum of Anticoagulation in Adult Patients With Staphylococcal Prosthetic Valve Endocarditis

Conundrum of Anticoagulation in Adult Patients With Staphylococcal Prosthetic Valve Endocarditis

Is Rifampin Use Associated With Better Outcome in Staphylococcal Prosthetic Valve Endocarditis? A Multicenter Retrospective Study.

International guidelines recommend rifampin-based combinations for staphylococcal prosthetic valve endocarditis (PVE). However, no robust clinical data support this recommendation, and rifampin tolerability is an issue. We aimed to evaluate the impact of rifampin for the treatment of staphylococcal PVE. An observational retrospective cohort study of all adults with staphylococcal PVE (modified Duke criteria) was conducted in 3 referral centers for endocarditis, during years 2000-2018. Primary outcome measurement was 1-year mortality. We enrolled 180 patients with PVE due to Staphylococcus aureus (n = 114, 63.3%), or coagulase-negative staphylococci (n = 66, 36.7%), on bioprosthesis (n = 111, 61.7%), mechanical valve (n = 67, 37.2%), or both (n = 2). There were 132 males (73.3%), and mean age was 70.4 ± 12.4 years. Valvular surgery was performed in 51/180 (28.3%) cases. Despite all isolates were susceptible to rifampin, only 101 (56.1%) were treated with rifampin, for a median duration of 33.0 days, whereas 79 (43.9%) received no rifampin. Baseline characteristics were similar in both groups. One-year mortality was, respectively, 37.6% (38/101), and 31.6% (25/79), in patients treated with, or without, rifampin (P = .62). Relapse rates were 5.9% (6/101), and 8.9% (7/79), P = .65. Patients treated with rifampin had longer hospital length-of-stay: 42.3 ± 18.6 vs 31.3 ± 14.0 days (P < .0001). On multivariate analysis, only cerebral emboli (odds ratio [OR] 2.95, 95% confidence interval [CI], 1.30-6.70, P = .009), definite endocarditis (OR 7.15, 95% CI, 1.47-34.77, P = .018), and methicillin-resistant S. aureus (OR 6.04, 95% CI, 1.34-27.26, P = .019), were associated with 1-year mortality. A large proportion (43.9%) of staphylococcal PVE received no rifampin. One-year survival and relapse rates were similar in patients treated with or without rifampin.

Gentamicin may have no effect on mortality of staphylococcal prosthetic valve endocarditis.

To analyze the influence of adding gentamicin to a regimen consisting of β-lactam or vancomycin plus rifampicin on survival in patients suffering from Staphylococcal prosthetic valve endocarditis (SPVE). From January 2008 to September 2016, 334 patients with definite SPVE were attended in the participating hospitals. Ninety-four patients (28.1%) received treatment based on β-lactam or vancomycin plus rifampicin and were included in the study. Variables were analyzed which related to patient survival during admission, including having received treatment with gentamicin. Seventy-seven (81.9%) were treated with cloxacillin (or vancomycin) plus rifampicin plus gentamicin, and 17 patients (18.1%) received the same regimen without gentamicin. The causative microorganism was Staphylococcus aureus in 40 cases (42.6%) and coagulase-negative staphylococci in 54 cases (57.4%). Overall, 40 patients (42.6%) died during hospital admission, 33 patients (42.9%) in the group receiving gentamicin and 7 patients in the group that did not (41.2%, P=0.899). Worsening renal function was observed in 42 patients (54.5%) who received gentamicin and in 9 patients (52.9%) who did not (p=0.904). Heart failure as a complication of endocarditis (OR: 4.58; CI 95%: 1.84-11.42) and not performing surgery when indicated (OR: 2.68; CI 95%: 1.03-6.94) increased mortality. Gentamicin administration remained unrelated to mortality (OR: 1.001; CI 95%: 0.29-3.38) in the multivariable analysis. The addition of gentamicin to a regimen containing vancomycin or cloxacillin plus rifampicin in SPVE was not associated to better outcome.

Rifampin for Surgically Treated Staphylococcal Infective Endocarditis: A Propensity Score-Adjusted Cohort Study

Rifampin is recommended as adjunctive treatment for staphylococcal prosthetic valve endocarditis (PVE). It is unclear whether this should hold for surgically treated patients. The purpose of this study was to examine whether adjunctive rifampin treatment in addition to cell wall active antimicrobial agents in patients with surgically treated staphylococcal infective endocarditis (IE) results in better outcomes. Patients operated on for staphylococcal IE from April 1, 2008, to July 1, 2014, were identified from ourinstitution's IE registry. Rifampin treatment was defined as 3 or more days of rifampin postoperatively. Cox proportional hazards regression was used to compare a composite outcome of death or reoperation for IE relapse, between patients treated and not treated with rifampin, adjusted for propensity to be treated with rifampin, methicillin resistance, all-purpose refined diagnosis related group (APR-DRG) severity score, and APR-DRG mortality risk. In all, 273 patients were identified. The mean age was 56 years, 66% were male, 50% had PVE, 60% had S.aureus or S.lugdunensis infection, 89% hadleft side involvement, and 57% had invasive disease. Fifty-one (27%) received 3 or more days of rifampin postoperatively. Ninety-two patients died orunderwent reoperation for IE relapse at a median of 205 days (interquartile range 56 to 718 days). In a multivariable model, patients treated with rifampin had a similar hazard of death or reoperation for IE relapse as those not treated (hazard ratio 0.76, 95% confidence interval 0.44 to 1.32, p value 0.34). The results were robust to varying definitions of rifampin treatment. Among patients with surgically treated staphylococcal IE there was insufficient evidence to claim a reoperation-free survival benefit from treatment with rifampin. Rifampin should not be used as adjunctive therapy for staphylococcal IE in patients who have undergone surgical procedures for its treatment.

P74 IS TRIPLE THERAPY NECESSARY IN STAPHYLOCOCCAL PROSTHETIC VALVE ENDOCARDITIS?

P74 IS TRIPLE THERAPY NECESSARY IN STAPHYLOCOCCAL PROSTHETIC VALVE ENDOCARDITIS?

Coagulase-negative staphylococcal prosthetic valve endocarditis—a contemporary update based on the International Collaboration on Endocarditis: prospective cohort study

Objective:To describe the contemporary features of coagulase-negative staphylococcal (CoNS) prosthetic valve endocarditis (PVE).Design:Observational study of prospectively collected data from a multinational cohort of patients with infective endocarditis. Patients with CoNS...

Asymptomatic Malaria Associated with Protection: Not Causal

An otherwise healthy 44-year-old woman (a resident of a mountainous region of Switzerland) presented to the emergency department with acute onset of fever myalgia and disorientation. On physical examination she was in shock without an evident infectious source. Laboratory analyses revealed leukocytosis (WBC count 27000_109 cells/L) and an elevated C-reactive protein level (260 mg/ L). The patient had a history of congenital left ventricular inflow and outflow tract obstruction that was surgically corrected at the age of 15 years. In 1986 and 1996 she had infectious endocarditis of the aortic valve due to Staphylococcus aureus; the aortic valve was replaced by a homograft in 1990. Transesophageal echocardiography showed vegetations on the aortic valve and possibly also on the mitral valve with severe aortic and moderate mitral regurgitation. Therapy with vancomycin gentamicin and rifampicin was initiated. Blood cultures grew methicillin-sensitive S. aureus supporting a diagnosis of S. aureus prosthetic valve endocarditis and treatment was changed to flucloxacillin and rifampicin. The clinical course was complicated by acute renal failure severe thrombopenia and multiple septic emboli (in the brain skin retina and spleen). After 4 weeks of antibiotic therapy the aortic and mitral valves were replaced by mechanical prostheses. Cultures of the aortic valve were sterile but broad-range eubacterial PCR had results positive for Coxiella burnetii. Serologic results confirmed chronic Q-fever (phase 1 IgG titer 1:6400; phase 1 IgA titer 1: 200; phase 2 IgG titer 1:12800; and phase 2 IgA titer 1:400); analysis of stored serum samples from the patient revealed that the infection had been acquired in the previous 12 months. Thus the final diagnosis was chronic Q-fever prosthetic valve endocarditis complicated by acute S. aureus prosthetic valve endocarditis. The postoperative course was uncomplicated. S. aureus prosthetic valve endocarditis was treated for a total of 6 weeks with flucloxacillin and rifampicin. For Q-fever endocarditis therapy with doxycycline and hydroxychloroquine was introduced and will be continued until the phase 1 IgG titer is !1:400 with a minimum treatment duration of 18 months. At the most recent follow-up visit 10 months after the initial presentation the patient was asymptomatic and titers of anti-Coxiella antibodies were decreasing (phase 1 IgG titer 1:3200; phase 1 IgA titer 1:50; phase 2 IgG titer 1: 6400; phase 2 IgA titer 1:100). This case is remarkable for the simultaneous implication of two different bacterial species in the pathogenesis of infective endocarditis with one of the pathogens being discovered incidentally. Reports in the literature on dual-pathogen endocarditis are scarce; 2 cases with concomitant streptococcal and Q-fever endocarditis have been previously described in a large prospective French study [1]. Our patient had underlying cardiac abnormalities predisposing her to C. burnetii endocarditis and resided in an area of Switzerland with a seroprevalence of Coxiella species infection up to 30% [2]. Nevertheless C. burnetii infection was not suspected because all clinical manifestations were compatible with staphylococcal prosthetic valve endocarditis. The diagnosis of Q-fever endocarditis was thus a lucky strike which is disconcerting given the poor prognosis of unrecognized chronic Coxiella infection. In view of our experience we believe that C. burnetii serologic analysis or PCR testing of heart valve tissue are worth performing in all patients with infective endocarditis who have a preexisting valvulopathy and live in a region in which Q-fever is endemic regardless of whether another etiological agent has been identified or not. (full-text)

Prosthetic valve endocarditis due to coagulase-negative staphylococci: findings from the International Collaboration on Endocarditis Merged Database

Infective endocarditis due to coagulase-negative staphylococci is increasingly recognized as a difficult-to-treat disease associated with poor outcome. The aim of this report is to describe the characteristics and outcome of patients with prosthetic valve endocarditis (PVE) due to coagulase-negative staphylococci versus those of patients with PVE due to Staphylococcus aureus and viridans streptococci. Patients were identified through the International Collaboration on Endocarditis Merged Database. A total of 54 cases of coagulase-negative staphylococci PVE, 58 cases of S. aureus PVE, and 63 cases of viridans-streptococci-related PVE were available for analysis. There was no difference between the three groups with respect to the type of valve involved or the rate of embolization. However, heart failure was encountered more frequently with coagulase-negative staphylococci (54%) than with either S. aureus (33%; p=0.03) or viridans streptococci (32%; p=0.02). In addition, valvular abscesses complicated 39% of infections due to coagulase-negative staphylococci compared with 22% of those due to S. aureus (p=0.06) and 6% of those due to viridans streptococci (p<0.001). Mortality was highest in patients with S. aureus and coagulase-negative staphylococcal endocarditis (47 and 36%, respectively; p=0.22) and was considerably lower in patients with viridans streptococcal endocarditis (p=0.002 compared to patients with coagulase-negative staphylococcal endocarditis). The results of this analysis demonstrate the aggressive nature of coagulase-negative staphylococcal PVE and the substantially greater morbidity and mortality associated with this infection compared to PVE caused by other pathogens.

Intracardiac Device and Prosthetic Infections: What Do We Know?

Intracardiac Device and Prosthetic Infections: What Do We Know?

Long term follow up of prosthetic valve endocarditis: what characteristics identify patients who were treated successfully with antibiotics alone?

OBJECTIVETo identify predictors for the safe use of antibiotic treatment without reoperation in patients with prosthetic valve endocarditis.SETTINGRetrospective study in a tertiary care centre.SUBJECTS AND DESIGNAll 49 episodes of definite...

Indices of effectiveness of medical and surgical treatment in 40 cases of prosthetic valve endocarditis.

Forty patients with prosthetic valve endocarditis (PVE) presenting during a 12-year period at a single hospital were studied. Twenty-six were male and 14 female and ages ranged from 19 to 67 years. During the first six post-operative months, most episodes were caused by staphylococci (38%) and Gram negative bacilli (24%). Between 6 and 11 months no episodes were seen, but thereafter streptococci predominated (50%). The overall mortality was 58% (66% during first six months; 36% thereafter). Nine of 23 patients undergoing re-operation died, most deaths occurring in patients in cardiac failure prior to surgery. Eleven deaths occurred in the 17 patients treated with antibiotics alone. Six of these were pyrexial at death and all but one was infected by a virulent organism. The remaining five were apyrexial at death and all had staphylococcal PVE. Our findings suggest: (1) all cases occurring during the first six months should be initially treated as 'early' PVE; (2) in staphylococcal PVE, apyrexia may not mean cure; (3) the principal guides to prognosis in PVE are the patient's cardiac status and the nature of the infecting organism.

Treatment of infective endocarditis: a 10-year comparative analysis.

The results of surgical and non-surgical treatment of active infective endocarditis in 182 patients over a 10-year period were analyzed. Heart failure, annular and myocardial abscesses, heart block, and coronary embolism, seen most frequently with staphylococcal and fungal endocarditis, were the primary causes of death in both native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). In NVE, surgery significantly improved the survival in patients with moderate or severe heart failure (P less than 0.05) and in all patients with staphylococcal endocarditis (P less than 0.03). In PVE, surgery significantly influenced survival in patients with moderate or severe heart failure (P less than 0.05) and in the entire group with late PVE (P less than 0.01). Early surgery is recommended for patients with native valve endocarditis and moderate or severe heart failure; those patients with staphylococcal NVE, regardless of hemodynamic state, should undergo early valve replacement. Early surgery is recommended for PVE patients with moderate or severe heart failure. We also recommend early valve replacement for early and late staphylococcal PVE.