Treatment Of Infective Endocarditis Research Articles

Association between surgical treatment and in-hospital mortality in patients with infective endocarditis stratified by NYHA classification: a nationwide retrospective study in Japan

Abstract Background Heart failure (HF) is one of the major complications of infective endocarditis (IE). The ESC guideline described that surgical treatment should be performed for the patients with IE complicated with HF. However, decision making of surgical indication in real-world clinical setting is not easy for patients with IE concomitant with HF due to complicated conditions, and the clinical benefit of surgical intervention for IE and HF is unclear. Purpose We sought to uncover the association between surgical treatment and in-hospital mortality among the patients admitted for community-acquired IE respectively according to the severity of HF symptoms (NYHA class I to IV). Methods We studied 3,403 patients diagnosed as IE (mean age 65.9 years, 61.6% males) with records of baseline NYHA classification (I to IV) who survived for more than 2 days, using the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan. Patients were classified into four groups: 919 patients (27.0%) in NYHA I, 1,007 patients (29.6%) in NYHA II, 767 patients (22.5%) in NYHA III, and 710 patients (20.9%) in NYHA IV. A multivariable logistic regression model adjusted for age, gender, Barthel Index, Charlson Comorbidity Index, and usage of inotropic therapy at admission was performed to evaluate the association between the surgical treatment and in-hospital mortality. Results Patients with higher NYHA classification were significantly older and were more likely to be female than those with lower NYHA classification. At admission, patients with higher NYHA classification had lower baseline activities and higher comorbidities, and also had more complications including stroke, shock and disseminated intravascular coagulation than those with lower NYHA classification. In-hospital mortality was seen in 406 patients (11.9%) in the entire cohort. The mortality rate significantly increased with the NYHA class (NYHA I, 3.6%; NYHA II, 8.4%; NYHA III, 11.9%; NYHA IV, 27.9%: p<0.001). According to the multivariable logistic regression analysis, surgical treatment was independently associated with lower in-hospital mortality (Odds ratio 0.395, 95% Confidence Interval 0.297–0.526; p<0.001). A fragmentated analysis in each NYHA classification showed that the survival benefit of surgical intervention was pronounced in patients with higher NYHA class (Figure). The limitation of our study was including the potential unmeasured confounders, which lead to overestimate the relationship between the surgical treatment and in-hospital mortality even after excluding the critically ill patients who died within 2 days and adjusting for the measured confounders. Conclusion Surgical treatment was associated with lower in-hospital mortality among the patients with IE complicated with HF, particularly among those with more advanced HF status. Our study implies that surgical treatment might be beneficial for the patients with advanced HF. Funding Acknowledgement Type of funding source: None

Daptomycin-based aminoglycoside-sparing therapy for streptococcal endocarditis: a retrospective multicenter study

Streptococci still represent common etiologic agents of infective endocarditis (IE). Although renal failure is frequently reported as an aminoglycoside-associated adverse event, last international guidelines recommend a beta-lactam/gentamicin combination therapy. We retrospectively evaluated the use of daptomycin-based aminoglycoside-sparing combination therapy for the treatment of streptococcal IE in seven referral hospitals in Italy. Retrospective, multicenter, observational study. All patients with streptococcal IE admitted from 2016 to 2018 were enrolled. Mortality and incidence of acute kidney injury (AKI) were compared between Group A (standard of care, SoC) and Group B (daptomycin-based aminoglycoside-sparing combination therapy). Fifty-four patients were enrolled, 33 in Group A and 21 in Group B. Mortality was 2/33 (6%) in Group A and 0 in Group B (p = 0.681); AKI incidence was 8/33 (24%) in Group A and 0 in Group B (p = 0.04). Daptomycin-based aminoglycoside-sparing combination therapy appears to be promising for the treatment of streptococcal endocarditis because of similar efficacy compared with SoC and significantly reduced incidence of AKI.

Dalbavancin for infective endocarditis: a single centre experience

Infective endocarditis (IE) is a life-threatening disease, mostly caused by gram-positive cocci, needing a 4–6 weeks antibiotic course. Dalbavancin is a lipoglycopeptide active on gram-positive microorganisms, with a unique pharmacokinetic profile. We describe our experience with dalbavancin to complete the intravenous antibiotic regimen for difficult-to-treat IE cases due to gram-positive bacteria. We treated 10 severely ill patients, each presenting several comorbidities. Seven patients were microbiologically cured from IE, but two patients experienced IE relapse due to the same microrganism. Short-term mortality after dalbavancin was nil, but late mortality (within 1 year of hospital discharge) was 60%. No death was related to dalbavancin therapy. Treatment was generally well tolerated. Dalbavancin may be an option to complete IE treatment in selected cases, once blood culture clearance and improvement of clinical conditions under standard therapy is reached, allowing shortening of hospitalization.

Dalbavancin in the Treatment of Bacteremia and Endocarditis in People with Barriers to Standard Care.

Introduction: Dalbavancin is an antibiotic administered by intravenous infusion weekly or bi-weekly and is currently FDA-approved only for treatment of skin and soft-tissue infections. It has shown promise, but is not considered the standard of care, for bacteremia and infective endocarditis (IE), which typically require outpatient parenteral antibiotic therapy (OPAT) for prolonged durations. People who inject drugs (PWID) with bacteremia or IE are often perceived as having barriers to OPAT and standard daily-administered antibiotics, prompting off-label use of dalbavancin in this population. Methods: A retrospective review of adult patients receiving at least one dose of dalbavancin for bacteremia or IE was conducted between 1 November 2017 and 31 October 2019. Outcomes and reasons for use of dalbavancin were recorded, including specific barriers to standard therapy. Results: Stated reasons for dalbavancin use in the 18 patients identified included active injection drug use (50%), inability to arrange standard OPAT due to patient adherence or inability to place in skilled nursing facility (SNF) (22%), risk for additional infections or other morbidity with OPAT (22%), and patient preference (6%). In 11 patients (61%) SNF placement was not attempted due to behavioral issues or patient declination. There were five patients who did not complete their intended course of treatment (28%). At 90 days, eight patients (44%) achieved a clinical or biologic cure, six (33%) failed treatment, and four (22%) were lost to follow-up. Conclusion: Dalbavancin may have a role as salvage therapy in the treatment of IE and bacteremia in PWID who have significant barriers to standard treatment.

Infection et TAVI

Since trans-catheter valve implantation (TAVI) has emerged for severe symptomatic aortic stenosis treatment, infective endocarditis (IE) appears as a rare but severe complication. Like surgical aortic valve remplacement infective endocarditis (SAVR-IE), TAVI-IE has a noxious impact on morbidity and mortality. Compared to SAVR-IE, TAVI-IE present some similarities as well as differences. Most TAVI-IE occurred during the first year and enterococcus is the more common pathogen. A multimodality imaging approach including echocardiography, multislice computed tomography (CT) and positron emission tomography-CT with blood culture is necessary for the diagnosis. In this high-risk population, the vast majority of TAVI-IE patients are treated with antibiotic therapy alone. Consequently to the expanded indication, the increasing number of TAVI-IE will appear more frequently. If initially only few clinical cases of IE were reported, sparse observational multicenter registries have now been published. Relevant differences were noted on these registries, but some recent publications have provided new informations on IE. The present review reports incidence, symptoms, microbiological profil, risk factors and clinicals outcomes of TAVI-IE. Eventually, we describe the management and the treatment of IE in the context of TAVI.

Infective endocarditis at a tertiary care hospital in South Korea

ObjectiveThe treatment of infective endocarditis (IE) has become more complex with the current myriad healthcare-associated factors and the regional differences in causative organisms. We aimed to investigate the overall trends,...

ANTIMICROBIAL ACTIVITY OF CEFTAROLINE AGAINST STAPHYLOCOCCUS AUREUS ISOLATED FROM PATIENTS WITH INFECTIVE ENDOCARDITIS WORLDWIDE (2010-2019)

SESSION TITLE: Chest Infections Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Ceftaroline is approved by the United States (US) Food and Drug Administration for community-acquired bacterial pneumonia and skin and skin-structure infections, including cases with concurrent bacteremia, and has demonstrated efficacy in cases of infective endocarditis (IE). We evaluated the antimicrobial activity of ceftaroline against S. aureus isolated from patients with IE. METHODS: 23,834 S. aureus isolates were collected consecutively from patients with bloodstream infections (BSI) from 2010 to 2019 via the SENTRY Antimicrobial Surveillance Program, including 396 isolates patients with a diagnosis of IE. IE isolates were collected from 19 medical centers in the US (n=124), 34 in Europe (EUR; n=213), and 22 in other geographic regions (n=59) and were tested for susceptibility against ceftaroline and comparators by reference broth microdilution method in a monitoring laboratory (JMI Laboratories). RESULTS: Among IE isolates, the overall oxacillin resistance (MRSA) rate was 29.0%, but this rate was higher in the US (40.3%) than EUR (25.4%) and other regions (18.6%). Ceftaroline was active against 95.2% of IE isolates (MIC50/90, 0.25/1 mg/L) and ceftaroline susceptibility was higher in the US (99.2%) and other regions (98.3%) than EUR (92.0%). Among oxacillin-susceptible (MSSA) isolates, the highest ceftaroline MIC value was 0.5 mg/L (94.7% inhibited at ≤0.25 mg/L). Among MRSA isolates from IE (n=115; MIC50/90, 1/2 mg/L), ceftaroline susceptibility was 98.0% in the US and 68.5% in EUR (90.9% in other regions; n=11). The highest ceftaroline MIC was only 2 mg/L and all ceftaroline-nonsusceptible isolates were categorized as susceptible dose dependent or intermediate (0.0% resistant). Dalbavancin (MIC50/90, ≤0.03/0.06 mg/L), daptomycin (MIC50/90, 0.25/0.5 mg/L), linezolid (MIC50/90, 1/2 mg/L), teicoplanin (MIC50/90, ≤2/≤2 mg/L), tigecycline (MIC50/90, 0.06/0.12 mg/L), and vancomycin (MIC50/90, 1/1 mg/L) exhibited complete activity (100.0% susceptible) against S. aureus from IE. Among all BSI S. aureus isolates (n=23,834), MRSA rates were 43.6% in the US and 25.6% in EUR, and ceftaroline susceptibility rates were 98.1% in the US and 95.4% in EUR. CONCLUSIONS: Ceftaroline exhibited potent in vitro activity against a large collection of S. aureus isolates recovered from patients with IE. Ceftaroline was particularly active against MRSA-causing BSI and IE in US medical centers. These results support further investigations to determine the role of ceftaroline in the treatment of IE. CLINICAL IMPLICATIONS: These results support further investigations to determine the role of ceftaroline in the treatment of IE. DISCLOSURES: No relevant relationships by Cecilia Carvalhaes, source=Web Response no disclosure on file for Rodrigo Mendes; Research Contractor relationship with Allergan Please note: $1001 - $5000 Added 03/11/2020 by Helio Sader, source=Web Response, value=Grant/Research Support no disclosure on file for Streit Streit

Implementation of the 2015 European Society of Cardiology guidelines for the management of infective endocarditis in the Netherlands.

Because the occurrence of infective endocarditis (IE) continues to be associated with high mortality, a working group was created by the Dutch Society of Cardiology to examine how the most recent European Society of Cardiology (ESC) guidelines for IE management could be implemented most effectively in the Netherlands. In order to investigate current Dutch IE practices, the working group conducted a country-wide survey. Based on the results obtained, it was concluded that most ESC recommendations could be endorsed, albeit with some adjustments. For instance, the suggested pre-operative screening and treatment of nasal carriers of Staphylococcus aureus as formulated in the ESC guideline was found to be dissimilar to current Dutch practice, and was therefore made less restrictive. The recently adapted ESC diagnostic criteria for IE were endorsed, while the practical employment of the relevant diagnostic techniques was simplified in an adapted flowchart. In addition, the presence of a multidisciplinary, so-called ‘endocarditis team’ in tertiary centres was proposed as a quality indicator. An adapted flowchart specifically tailored to Dutch practice for microbiological diagnostic purposes was constructed. Lastly, the working group recommended the Stichting Werkgroep Antibioticabeleid (SWAB; Dutch Working Party on Antibiotic Policy) guidelines for IE treatment instead of the antibiotic regimens proposed by the ESC.

Infective endocarditis by Proteus species: a systematic review.

Proteus spp. are members of the Enterobacteriaceae family and are Gram-negative, rod-shaped bacteria known to mainly cause urinary tract infections (UTIs) in humans. However, even though scarce evidence exists suggesting their potential to cause infective endocarditis (IE), a study summarizing the existing evidence is lacking. The purpose of this study was to systemically review all published cases of IE by Proteus species in the literature. A systematic review of PubMed, Scopus and Cochrane Library (through 5th May 2020) for studies providing epidemiological, clinical and microbiological data as well as data on treatment and outcomes of IE by Proteus species was performed. A total of 16 studies, containing data of 16 patients, were included. A prosthetic valve was present in 25%, while the most common causative pathogen was P. mirabilis. Aortic valve was the most common infected site in 33.3%, followed by mitral valve in 26.7%. Diagnosis was set with transesophageal echocardiography in 37.5%, and transthoracic echocardiography in 25%, while the diagnosis was set at autopsy in 25%. Fever and sepsis were present in 100% and 84.6%, respectively. Aminoglycosides and cephalosporins were the most common antimicrobials used for treatment. Clinical cure was noted in 62.5%, while overall mortality was 43.8%. This systematic review describes IE by Proteus species in detail and provides information on epidemiology, clinical presentation, treatment and outcomes.

Surgical treatment of infective endocarditis: Results in 831 patients from a single center.

This study evaluated surgical outcomes of infective endocarditis (IE), with particular attention to the impact of intravenous drug use (IVDU). Adult patients undergoing surgery for IE between 2011 and 2018 at a single center were included and stratified by IVDU. The primary outcome was overall survival. Secondary outcomes included postoperative complications and hospital readmissions. Kaplan-Meier and multivariable Cox regression were utilized for unadjusted and risk-adjusted survival analyses, respectively. Cumulative incidence function curves were compared for hospital readmissions. A total of 831 patients (mean age 55 years, 34.4% female) were operated on for IE, including 318 (38.3%) with IVDU. Cultures were most commonly positive for streptococcus (25.2%), methicillin-sensitive Staphylococcus aureus (17.7%), enterococcus (14.3%), or methicillin-resistant Staphylococcus aureus (8.4%). The most common procedures included isolated aortic valve repair/replacement (18.8%), aortic root replacement (15.9%), mitral valve repair/replacement (26.7%), aortic and mitral valve replacement (8.4%), and tricuspid valve repair/replacement (7.6%). Mean follow-up was 3.4 ± 2.4 years. Overall 5-year survival was 64% and was similar between IVDU and non-IVDU. Multivariable analysis demonstrated that IVDU was not associated with mortality risk. IVDU patients displayed higher rates of all-cause readmission (61.6% vs 53.9%; P = .03), drug-use readmission (15.4% vs 1.4%; P < .001), and recurrent endocarditis readmission (33.0% vs 13.0%; P < .001). The majority of patients undergoing surgical treatment of IE are alive at 5-years although readmission rates are high. IVDU is not a risk factor for longitudinal mortality although patients with IVDU are at higher overall readmission risk, driven largely by greater readmissions for drug-use and recurrent endocarditis.

Infective Endocarditis Guidelines: The Challenges of Adherence-A Survey of Infectious Diseases Clinicians.

BackgroundGuidelines exist to aid clinicians in managing patients with infective endocarditis (IE), but the degree of adherence with guidelines by Infectious Disease (ID) physicians is largely unknown.MethodsAn electronic survey assessing adherence with selected IE guidelines was emailed to 1409 adult ID physician members of the Infectious Diseases Society of America’s Emerging Infections Network.ResultsFive hundred fifty-seven physicians who managed IE responded. Twenty percent indicated that ID was not consulted on every case of IE at their hospitals, and 13% did not recommend transthoracic echocardiography (TTE) for all IE cases. The duration of antimicrobial therapy was timed from the first day of negative blood cultures by 91% of respondents. Thirty-four percent of clinicians did not utilize an aminoglycoside for staphylococcal prosthetic valve IE (PVE). Double β-lactam therapy was “usually” or “almost always” employed by 83% of respondents for enterococcal IE. For patients with active IE who underwent valve replacement and manifested positive surgical cultures, 6 weeks of postoperative antibiotics was recommended by 86% of clinicians.ConclusionsThe finding that adherence was <90% with core guideline recommendations that all patients with suspected IE be seen by ID and that all patients undergo TTE is noteworthy. Aminoglycoside therapy of IE appears to be declining, with double β-lactam regimens emerging as the preferred treatment for enterococcal IE. The duration of postoperative antimicrobial therapy for patients undergoing valve replacement during acute IE is poorly defined and represents an area for which additional evidence is needed.

Impact of Chronic Renal Failure on Surgical Outcomes in Patients With Infective Endocarditis

Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied. Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival. Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P < .05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P < .05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P < .001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively. In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.

Outcomes of surgical treatment for active infective endocarditis of mitral valve compared using complexity scoring.

The aim of this study was to evaluate our surgical treatment outcomes of active infective endocarditis (IE) of mitral valve in relation to the patients' complexity scores. We reviewed 51 patients who underwent surgical treatment for active IE on the mitral valve, in our hospital between September 2002 and November 2016. We adapted a complexity scoring scale to describe the range of parts suffering vegetation and damage, assigning the following weighting: weight 1 for each posterior segment; weight 2 for each anterior segment, commissural segment, left atrium, or left ventricle; weight 3 if the annulus was involved or if pathology extended to a prior mitral operation site. A total of 51 patients were identified and categorized by complexity score into two groups: 1-2: Simple (n = 19); ≥ 3: Complex (n = 32). MV repair was achieved in 18 patients (95%) in the Simple group and 26 patients (81%) in the Complex group. In the Complex there were 2 in-hospital deaths (6%). There were none in the Simple. The 5-year survival rates were 100% in the Simple and 79.6% in the Complex (P < 0.05). The 5-year rates of freedom from mitral regurgitation were 77.8% in the Simple and 91.5% in the Complex (P = 0.63). The 5-year rates of freedom from recurrence of IE were 93.3% in the Simple and 92.2% in the Complex (P = 0.76). We found consistent outcomes in terms of recurrent mitral regurgitation and recurrence of IE, regardless of lesion complexity.

Clinical Outcomes Associated With the Use of Anticoagulant and Antiplatelet Agents in Patients Undergoing Treatment for Infective Endocarditis: A Pilot Study

PurposeThe use of antithrombotic therapy may increase morbidity and mortality in patients with infective endocarditis (IE). This study evaluated the use of oral anticoagulant and antiplatelet agents on the development of embolic complications and bleeding episodes within 30 days of IE diagnosis. MethodsThis pilot study was a retrospective medical record review of patients receiving treatment for IE between July 1, 2012, and July 31, 2017. The 2 study arms were patients receiving long-term anticoagulant/antiplatelet therapy versus patients not receiving therapy at the time of IE. Patients were eligible for inclusion if they had definite IE per modified Duke criteria and received at least 48 h of antibiotic therapy. The primary and secondary outcomes evaluated the incidence of embolic phenomenon and bleeding events in each group, respectively. FindingsOf 129 patients with IE, 34 met the eligibility criteria, with 20 patients on receiving anticoagulant/antiplatelet therapy and 14 patients not receiving anticoagulant/antiplatelet therapy. The median age was 63 years, with 50% male patients. Staphylococcus aureus was the infecting pathogen in 41% of patients. Embolic events occurred in 30% of patients receiving anticoagulant/antiplatelet therapy versus 7.1% of those not receiving therapy. No patients in the anticoagulant/antiplatelet therapy arm experienced a bleeding event, whereas 7.1% of those in the comparator arm did. ImplicationsThis retrospective pilot study indicates that patients with IE receiving anticoagulant/antiplatelet agents may be at an increased risk for embolic episodes versus those who are not. Larger, prospective studies are necessary to find a definitive correlation.

Diagnosis and treatment of infective endocarditis in pregnancy: a case report

BackgroundPregnancy with infective endocarditis (IE) is rare, but the fetal and maternal mortality rates of these pregnancies are very high, making IE a serious threat to the safety of pregnant women and their fetuses. Therefore, for pregnant women with recurrent fever, a detailed medical history and physical examination should be performed, echocardiography and blood culture should be carried out as soon as possible, multidisciplinary consultation should be implemented, and a diagnosis and treatment plan should be formulated right away, as this is key to saving the lives of mothers and infants.Case introductionA 30-year-old pregnant Chinese woman had IE at 26 weeks of gestation. After close monitoring and care until 31 weeks of gestation, she underwent a successful delivery, cardiac surgery, repair of the patent ductus arteriosus (PDA), mitral valvuloplasty (MVP) and removal of the vegetations. The operation was successful, and further follow-up evaluation showed no abnormality.ConclusionFor the diagnosis and treatment of IE in pregnancy, it is of great importance to implement an individualized diagnosis and treatment plan in combination with close monitoring by echocardiography and to select the right time for cardiac surgery and termination of pregnancy.

Oral antibiotics for infective endocarditis: a clinical review.

Current guidelines for management of infective endocarditis (IE) advise 4-6 weeks of IV antibiotics. This is based on historical data from animal models, which set a precedent for high peak serum antimicrobial levels, thought to be only achievable with IV therapy. However, there has been increasing recent interest in oral antibiotics as an alternative to prolonged parenteral therapy, not limited to treatment of IE. This review examines the theory behind parenteral antibiotic administration with reference to the MICs of relevant pathogens. By comparing published serum antimicrobial levels after oral and IV administration we suggest that safe levels of commonly used antibiotics can be achieved orally. We have then reviewed the literature to date on oral antibiotics for IE. The largest randomized controlled trial (RCT) in this area, the POET trial, concluded that oral therapy was non-inferior to prolonged IV therapy in stable patients with left-sided IE. Additionally, there have been two smaller RCTs published, as well as a number of observational studies over the last 50 years, utilizing a variety of different patient groups, methods and treatment strategies. This body of evidence gives weight to a potential shift in practice towards oral therapy, primarily as a step-down treatment. We conclude that pharmacological data offer theoretical reassurance for the safety of oral therapy. This is coupled with a growing evidence base for non-inferiority of oral antimicrobials compared with prolonged parenteral therapy in practice.

The Ross procedure is a safe and durable option in adults with infective endocarditis: a multicentrestudy.

Surgical treatment of infective endocarditis (IE) remains a challenge. The Ross procedure offers the benefit of a living substitute in the aortic position but it is a more complex operation which may lead to increased operative risk. The aim of this study was to assess the safety and late outcomes of the Ross procedure for the treatment of active IE. From 2000 to 2019, a total of 31 consecutive patients underwent a Ross procedure to treat active IE (mean age 43 ± 12 years, 84% male). All patients were followed up prospectively. Four patients (13%) were intravenous (IV) drug users and 6 patients (19%) had prosthetic IE. The most common infective organism was Streptococcus (58%). Median follow-up was 3.5 (0.9-4.5) years and 100% complete. There were no in-hospital deaths. One patient suffered a postoperative stroke (3%) and 1 patient (3%) required reintervention for bleeding. Three patients had a new occurrence endocarditis: 2 patients were limited to the pulmonary homograft and successfully managed with IV antibiotics, whereas 1 IV drug user patient developed concomitant autograft and homograft endocarditis. Overall, cumulative incidence of IE recurrence was 13 ± 8% at 8 years. The cumulative incidence for autograft endocarditis was 5 ± 4% at 8 years. Two patients (6%) died during follow-up, both from drug overdoses. At 8 years, actuarial survival was 88 ± 8%. In selected patients with IE, the Ross procedure is a safe and reasonable alternative with good mid-term outcomes. Freedom from recurrent infection on the pulmonary autograft is excellent, labelporting the notion that a living valve in the aortic position provides good resistance to infection. Nevertheless, in IV drug user patients, pulmonary homograft endocarditis remains a challenge. Continued follow-up is needed to ascertain the long-term benefits of this approach.

Outcome of surgery for acute infective endocarditis: does preoperative stroke have an impact on mortality?

Surgical therapy of infective endocarditis (IE) is challenging and can be associated with high mortality. In this study, we present the early outcomes of patients who underwent cardiac surgery for IE. From 2017 until 2019, 66 patients underwent surgical treatment for IE. Staphylococcus aureus infection was identified in 14 patients (21%). In the same period, about 813 valve replacement procedures were performed with 8% incidence of IE. Mean age was 66 ± 12years and 32% were females. Mean ejection fraction was 55 ± 9%. Seven patients (11%) had stroke due to septic embolism preoperatively. In 20 patients (30%), prosthetic valve endocarditis was an indication for reoperation. Thirty-day postoperative mortality and impact of preoperative stroke were analyzed. Thirty-day mortality was 17% (n = 11). Mean EuroSCORE I was 28 ± 22%. Mean cross clamp time was 63 ± 37min. Fourty patients (61%) underwent one-valve procedure, 25 patients (38%) had double-valve, and one (1%) triple-valve operation. All seven patients with preoperative neurologic dysfunction had unremarkable postoperative course without death or neurologic deterioration. Five of them had no worsening in neurological status, while 2 patients had slight improvement in speech. The comparison between the two groups (patients without preoperative neurological vs. patients with preoperative neurological dysfunction) revealed no significance in the postoperative mortality rate (18% vs. 0% with p = 0.26). Postoperative echocardiography revealed competent valve function in all cases. Surgical treatment for IE still remains a challenge with high morbidity and mortality. Patients with preoperative neurologic dysfunction due to septic embolism have good early postoperative results without increased mortality.

Consensus Report on Diagnosis, Treatment and Prevention of Infective Endocarditis by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Clinical Microbiology and Infectious Diseases (KLIMIK), Turkish Society of Cardiology (TSC), Turkish Society of Nuclear Medicine (TSNM), Turkish Society of Radiology (TSR), Turkish Dental Association (TDA) and Federation of Turkish Pathology Societies (TURKPATH) Cardiovascular System Study Group

Infective endocarditis (IE) is rare, but associated with significant morbidity and mortality rates. Estimates of the incidence of IE in Turkey are compromised by the absence of population-based prospective studies. Due to the frequent presence of predisposing cardiac conditions and higher rates of nosocomial bacteremia in highrisk groups, the incidence of IE is expected to be higher in Turkey. Additionally, while IE generally affects older people in developed countries, it still affects young people in Turkey. In order to reduce the mortality and morbidity, it is critical to diagnose the IE to determine the causative agent and to start treatment rapidly. However, most of the patients cannot be diagnosed in their first visits, about half of them can be diagnosed after three months, and the disease often goes unnoticed. In patients diagnosed with IE, the rate of identification of causative organisms is significantly lower in Turkey than in developed countries. Furthermore, most of the centers do not perform some essential microbiological diagnostic tests as a routine practice. Some antimicrobials that are recommended as the first-line of treatment for IE, particularly antistaphylococcal penicillins, are not available in Turkey. These problems necessitate reviewing the epidemiological, laboratory, and clinical characteristics of IE in our country, as well as the current information about its diagnosis, treatment, and prevention together with local data. Physicians can follow patients with IE in many specialties. Diagnosis and treatment processes of IE should be standardized at every stage so that management of IE, a setting in which many physicians are involved, can always be in line with current recommendations. Study Group for Infective Endocarditis and Other Cardiovascular Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases has called for collaboration of the relevant specialist organizations to establish a consensus report on the diagnosis, treatment, and prevention of IE in the light of current information and local data in Turkey.

Tempestuous Course of Enterococcus Infective Endocarditis — From Daptomycin Lung Toxicity to Successful Treatment With Surgery and Fosfomycin Combination Therapy

Abstract Management of enterococcal infective endocarditis (IE) is one of the intriguing challenges in infectious diseases. Ampicillin with gentamicin is the standard therapy for susceptible Enterococcus faecalis. However, in presence of β-lactam-resistant isolates, nephroxicity, or allergy to β-lactams, alternatives like glycopeptides and daptomycin have been used for the treatment of enterococcus IE. We report a patient with E. faecalis IE who had allergy to β-lactam and during treatment had developed daptomycin lung toxicity. He was subsequently treated with intravenous fosfomycin and surgery with aortic valve replacement.