Treatment Of Infective Endocarditis Research Articles

Risk-benefit Assessment of Systematic Thoracoabdominal-pelvic Computed Tomography in Infective Endocarditis.

In the management of infective endocarditis (IE), the presence of extracardiac complications has an influence on both diagnosis and treatment. Current guidelines suggest that systematic thoracoabdominal-pelvic computed tomography (TAP-CT) may be helpful. Our objective was to describe how systematic TAP-CT affects the diagnosis and the management of IE. In this multicenter cohort study, between January 2013 and July 2016 we included consecutive patients who had definite or possible IE according to the Duke modified criteria, validated by endocarditis teams. We analyzed whether the Duke classification and therapeutic management were modified regarding the presence or the absence of IE-related lesion on CT and investigated the tolerance of this examination. Of the 522 patients included in this study, 217 (41.6%) had 1 or more IE-related lesions. On the basis of CT results in asymptomatic patients, diagnostic classification was upgraded from possible endocarditis to definite endocarditis for only 4 cases (0.8%). The presence of IE-related lesions on CT did not modify the duration of antibiotic treatment (P = .55), nor the decision of surgical treatment (P = .39). Specific treatment of the lesion was necessary in 42 patients (8.0%), but only 9 of these lesions (1.9%) were asymptomatic and diagnosed only on the TAP-CT. Acute kidney injury (AKI) within 5 days of CT was observed in 78 patients (14.9%). The TAP-CT findings slightly affected diagnosis and treatment of IE in a very small proportion of asymptomatic patients. Furthermore, contrast media should be used with caution because of the high risk of AKI.

Urgent Surgical Treatment of Aortic Endocarditis in Infants and Children.

Infective endocarditis (IE) in the pediatric population can present asa life-threatening condition. Optimal timing for surgical intervention should consider surgical risks versus the risk of neurologic complications. We herein report our experience with this group of critically ill children. Retrospective analysis of patient charts of all patients who underwent urgent surgical treatment of aortic IE from 1994 to 2014 was performed. Nine patients with acute storming IE of the aortic valve or the ascending aorta were urgently operated (eight normal heart, one congenital aortic stenosis), age ranged from 8weeks to 4.2years. Causative organisms were Staphylococcus aureus (2), Staphylococcus coagulase negative (1), Kingella kingae (2), Streptococcus pneumoniae (2), or culture negative (2). Presenting symptoms other than hemodynamic instability were neurologic decompensation (5) coronary embolization (1) and cardiogenic shock due to scalded skin syndrome (1). CT and MRI demonstrated significant brain infarcts in four patients. Operations performed were the Ross operation (7) and ascending aortic reconstruction (2). There were no operative deaths. At a median follow-up of 6years (range 2-196months), all patients are alive and well. Re-intervention included homograft replacement (2) and transcatheter Melody valve implantation (1). At their last follow-up, the neo-aortic valvewas functional in all patients with minimal regurgitation and all had full resolution of the neurological deficits. Urgent surgical treatment for aortic valve IE in infants is challenging. Although surgery is complex and pre-disposing conditions such as sepsis, neurologic and cardiac decompensations are prevalent, operative results are excellent and gradual and significant neurologic improvement was noted over time.

Early surgery with aggressive surgical approach to improve 6-month outcomes in patients with active infective endocarditis: contribution of cerebral preoperative magnetic resonance imaging.

We investigated the hypothesis that early surgery for infective endocarditis (IE) attenuates the rate of death or embolic events and does not increase the rate of relapse or postoperative valvular dysfunction (PVD) at 6 months. 21 consecutive patients who underwent surgical treatment of IE were prospectively included. We assessed 6-month postoperative clinical outcomes by comparing early surgery (Group E, surgery within 72h) and conventional treatment (Group C). Nine patients (43%) were assigned to Group E based on a combination of preoperative evaluation parameters, including the findings of cerebral magnetic resonance imaging (MRI), which was performed in all patients with left-sided IE. Six surgical plans (5 advancements and 1 postponement) were modified by routine MRI. Although preoperative echocardiography did not confirm all annular invasions, the rate of periannular infection, which was treated by pericardial annular patch plasty (56%) in patients with native-valve IE, was higher in Group E than C (P = 0.006). Early surgery based on MRI findings resulted in no postoperative embolic events or cerebral bleeding. The 6-month mortality rate was 0% in both groups, although the calculated 6-month IE mortality rate was 49.2 ± 25% and 28.8 ± 18%, respectively. No recurrence of IE or PVD occurred in Group E. The 6-month rate of freedom from composite events was 100% in Group E. Aggressive treatment (periannular resection and disuse of a prosthetic annuloplasty ring) and optimal antibiotic therapy based on intraoperative microorganisms, even in patients who underwent early surgery, reduced the 6-month relapse and PVD rates.

Invited Commentary

Invited Commentary

Long-term prognosis after surgery for infective endocarditis: Distinction between predictors of early and late survival

ObjectivesCardiac surgery is a life-saving procedure in patients diagnosed with infective endocarditis (IE). There are several validated risk scores developed to predict early-mortality; nevertheless, long-term survival has been less investigated. The aim of the present study is to analyze the impact of IE-specific risk factors for early and long-term mortality. MethodsAn observational retrospective study was conducted that included all patients who underwent surgery for IE from 2002 to 2016. Median follow-up time after surgery was 53.2 months (IQI 26.2–106.8 months). In-hospital mortality was analyzed using multiple logistic regression. Long-term survival was analyzed after one, two and five years. Cox proportional hazards regression was employed to identify risk factors related to long-term mortality. ResultsOf the 180 patients underwent cardiac surgery, 133 were discharged alive (in-hospital mortality was 26.11%). 6 variables were identified as independent factors associated with in-hospital mortality, most of them closely related to the severity of IE: age, multivalvular involvement, critical preoperative status, preoperative mechanical ventilation, abscess and thrombocytopenia.Long-term survival in patients discharged alive was 89.1%, 87.4% and 77.6% after one, two and five years. Long-term mortality was independent of specific IE factors and 86.51% of deaths were not related to cardiovascular or infectious diseases. ConclusionDespite the high perioperative mortality rate after surgical treatment for active IE, long-term survival after hospital discharge was acceptable, regardless of the severity of the endocarditis episode. Although in-hospital survival depended mainly on several IE factors, long-term survival was not related to the severity of endocarditis baseline affection.

Surgery for acute infective endocarditis: epidemiological data from a Spanish nationwide hospital-based registry.

Infective endocarditis (IE) is a serious and eventually lethal disease with rising incidence in the past couple of decades. The aim of this study was to evaluate the contemporary epidemiological trends of surgical endocarditis patients, to analyse the clinical outcomes and to study their profile, associated prognostic factors and costs. This is a retrospective study of all patients admitted for IE in Spanish hospitals and discharged between 1 January 1997 and 31 December 2014. Data were extracted from the minimum basic data set of the National Surveillance System for Hospital Data in Spain provided by the Spanish Ministry of Health. Hospitalizations, comorbidities, outcomes and costs were analysed. In total, 34 399 patients with IE were included; 15.7% of patients received surgical treatment and 84.3% received medical treatment only. Surgical patients were mostly men (71.9%) and had a lower mean age (59.2 ± 16.08 years) than the medical treatment group (P < 0.0001). Mortality among surgical patients showed a decreasing trend between 1997 (32.0%) and 2014 (22.7%) and increased with age (47.6% in ≥85 years of age). Length of hospital stay and the percentage of patients with organ dysfunction were also higher in this group. The cost of the surgical treatment group was higher and increased since 1997 (15 259.22 euros), remaining stable from 2010 (40 700 euros) (P < 0.0001). Surgical treatment in IE has trended upwards in Spain during the last 2 decades. Patients are getting older and more frequently experience organ dysfunction. Mortality ratio steadily declined without changes in the length of hospital stay.

Descriptive Epidemiological, Clinical and Microbiological Features of Infective Endocarditis at a University Hospital in Saudi Arabia

Infective Endocarditis (IE) still remains a serious disease. The treatment and pathology still remain unclear. In this study, we sought to clarify the epidemiology and treatment of IE in a teaching hospital in Saudi Arabia. In this study, we sought to conduct a retrospective investigation of all adult patients who were treated for IE at our hospital and determine the characteristic demographic, clinical and pathological features. Our findings indicate that the main risk factors of IE were surgical intervention (28%) and structural heart disease (20%). The mean (SD) age of the patients in our study was 48 (18). The most common organisms identified were Staphylococcus aureus (40%) and Streptococcus viridans (30%). The most common clinical presentations were anorexia, weight loss and shortness of breath. IE was accompanied by valvular dysfunction in most cases (83%) and vegetation (55%). About 83% of the patients had undergone transthoracic echocardiography. Our findings provided some insight into the current trends in the epidemiology and clinical features of IE in Saudi Arabia.

Successful treatment of a penicillin-intermediate and ceftriaxone-resistant Granulicatella adiacens presumed prosthetic valve endocarditis with vancomycin

Advancements in rapid diagnostics have helped to identify nutritionally variant streptococci (NVS) as an increasing cause of infective endocarditis (IE). This case report highlights the challenges in susceptibility testing and the importance of appropriate empiric treatment for Granulicatella adiacens, and provides considerations for future practice guideline recommendations. Guidelines for treatment of IE caused by NVS are currently limited to patients with native valve disease. We present a patient with presumed prosthetic valve endocarditis caused by G. adiacens, with clinically relevant resistance to recommended first–line agents (penicillin and ceftriaxone), who was successfully treated with 8 weeks of intravenous (IV) vancomycin. Vancomycin is currently recommended as an alternate therapy for patients intolerant of penicillins, but we believe vancomycin should be considered a first–line empiric treatment option for IE when the identified organism is G. adiacens and susceptibility testing is not readily available.

Infective endocarditis presenting as back pain

A 51-year-old healthy man presented to emergency department with complaints of severe low back pain for 3 days and 2-week history of low-grade fever. Because of persistent back pain with fever up to 38 ℃, we ordered contrast-enhanced abdominal computed tomography (CT) which showed a huge aortic thrombus at the level of aortic bifurcation. Transthoracic two-dimensional echocardiography showed a vegetation at anteromedial leaflet of mitral valve, and infective endocarditis (IE) was diagnosed. After long-term broad-spectrum antibiotics and arterial embolectomy with mitral valve replacement, he discharged uneventually. Early diagnosis and treatment of IE at emergency department may be the key to the better result.

Pulmonary artery intravascular abscess: A rare complication of incomplete infective endocarditis treatment in the setting of injection drug use.

Infective endocarditis (IE) is a serious complication of injection drug use. Right-sided IE encompasses 5–10% of all IE cases, with the majority involving the tricuspid valve (TV). The predominant causal organism is Staphylococcus aureus. Most cases of right-sided IE can be successfully treated with antimicrobials, but approximately 5–16% require eventual surgical intervention. We report the case of a 36-year-old female with active injection drug use who developed methicillin-sensitive Staphylococcus aureus IE of the tricuspid valve. Associated with poor adherence to medical therapy as a consequence of opioid addiction, she developed septic emboli to the lungs and an intravascular abscess in the left main pulmonary artery. These long-term potentially fatal, sequelae of incompletely treated IE require surgical intervention, as medical therapy is unlikely to be sufficient. Surgical management may involve TV replacement, pulmonary artery resection, and pneumonectomy. Prevention of these complications may have been achieved by concurrent opioid addiction therapy. An intravascular pulmonary artery abscess is a novel complication of advanced IE that has not been previously reported. This complication likely arose due to incomplete IE treatment as a consequence of opioid addiction, highlighting the need for concurrent addiction management. Intravenous antimicrobial therapy is likely not adequate, and surgical intervention, including pulmonary artery resection and pneumonectomy may be necessary.

Early Operation in Patients With Mitral Valve Infective Endocarditis and Acute Stroke Is Safe

To determine if preoperative embolic stroke is associated with an increased risk of postoperative stroke among patients undergoing early operation for mitral valve (MV) infective endocarditis (IE), we compared outcomes among patients presenting with and without acute stroke. From 2003 to 2015, 243 consecutive patients underwent surgery for active MV IE. Patients were categorized into 2 groups: 72% (174 of 243 patients) with no preoperative acute stroke (clinical, radiographic or both) and 28% (69 of 243 patients) with stroke. Both preoperative and postoperative strokes were confirmed in all patients with brain computed tomography or magnetic resonance imaging and comprehensive examination by a neurologist. Among patients presenting with stroke, 33% (23 of 69 patients) were asymptomatic and had only positive imaging findings. The median time from admission to operation was 5 days. The overall rate of new postoperative stroke was 4% (10 of 243 patients). The rate of postoperative stroke was not different between the 2 groups: 4% (7 of 174 patients) among patients with no preoperative stroke and 4% (3 of 69 patients) with stroke (p= 0.9). One patient developed a hemorrhagic conversion of an acute infarct. Operative mortality was 7% (13 of 174 patients) among patients with no preoperative stroke and 7% (5 of 69 patients) among patients with stroke (p=0.9). MV surgery for IE and acute stroke can be performed early with a low risk of postoperative neurologic complications. When indicated, surgical intervention for MV IE complicated by acute stroke should not be delayed.

Efficiency of a self-administered outpatient parenteral antimicrobial therapy (s-opat) for infective endocarditis within the context of a shortened hospital admission based on hospital at home program

ABSTRACTObjective: This study aimed to evaluate the efficiency of treatment of infectious endocarditis (IE) via Self-administered Outpatient Parenteral Antimicrobial Therapy (S-OPAT) supported by a shortening hospital admission program in a hospitalization-at-home unit (HAH), including a short review of the literature.Methods: Ambispective cohort study of 57 episodes of IE in 54 patients treated in an HAH unit between 1988 and 2014 who receive S-OPAT after prior intra-hospital clinical stabilization. Characteristics of each episode of IE, safety and efficiency of the care model, were analyzed.Results: Forty-three (76%) patients were males with a median age of 61 years (SD = 16.5). A total of 37 (65%) episodes affected the native valve (42% the aortic valve). In 75%, a micro-organism was isolated, of which 88% were Gram-positive bacteria. No deaths occurred during HAH program, clinical complications appeared in 30% of episodes, only 6 patients were re-admitted to hospital although no patient died. In the 12 months’ follow-up 3 cases had a recurrence. The average cost of a day stay in HAH was €174 while in traditional cardiology hospitalization was €1100. The total average cost of treatment of each episode of IE managed entirely in hospital was calculated as €54,723. Application of the S-OPAT model based on HAH meant a cost reduction of 32.72%.Conclusions: In suitably selected patients, treatment of IE based on S-OPAT supported by a shortening hospital admission care program by means of referral to a HAH unit is a safe and efficient care model which entails a significant cost saving for the public healthcare system.

Aetiology of renal failure in patients with infective endocarditis. The role of antibiotics

Background and objectivesThe possible renal toxicity of certain antibiotics (AB) is well known. The objective of our work is to know the possible effect of AB treatments in the development of renal failure (RF) in patients with infective endocarditis (IE). Material and methodCollection from a national multi-centre registry of collection on renal function, both prior and its impairment, if any, during the treatment of IE and in relation to possible causative factors, including the use of AB. ResultsBetween 2008 and 2012, 1853 episodes of IE reported from 26 Spanish centres were analyzed. Of these, 21.6% had prior RF. They developed new RF or impairment of renal function in 38.7% of the cases. In patients with prior RF, impairment was more frequent (64 vs 31.7%, p<0.001). Overall, patients with RF were older (70.6 vs 67 years, p<0.01), had more comorbidities (Charlson index 5 vs 4, p<0.01), and IE by Staphylococcus aureus (32.1 vs 16.5%, p<0.01). Potentially nephrotoxic AB use was only associated with RF in patients without prior RF (aminoglycosides: OR=1.47 [95% CI 1.096–1.988], p=0.010; aminoglycosides with vancomycin: OR=1.49 [95% CI 1.069–2.09], p=0.019). ConclusionsIn patients without prior RF, the use of nephrotoxic AB is associated with impairment of renal function. In patients with RF prior to the IE episode, impairment of renal function was more frequent but appears to be more related to the severity of infection.

Is a Negative Transesophageal Echocardiogram Enough to Stop Treatment?

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Infective Endocarditis (IE) is one of the most life threatening diseases. Echocardiography is a key tool used in diagnosing IE. There are times however when clinical suspicion outweighs diagnostic tests. CASE PRESENTATION: 35-year-old female presented with fever, joint pains, vomiting and a rash. Patient's medical history is significant for a bicuspid aortic valve and an ascending aortic aneurysm with a graft repair. Blood pressure was 93/66 and other vitals were within normal limits. Her physical exam was significant for generalized pustules (palms, soles, face), 2x2 cm ulcerated lesion on the tip of the 3rd right digit, and asymmetric joint tenderness. Cardiovascular exam was significant for Grade II Aortic, Crescendo murmur. Initial labs showed white blood cells count of 20.1 K/uL, Creatinine 2.11 mg/dL, CRP 275 mg/L, ESR 67 MM/HR. Blood cultures were positive for Staphylococcus Aureus. A transesophageal echocardiogram (TEE) showed a bicuspid aortic valve, and no evidence of valvular vegetation. Despite the lack of evidence on TEE, patient treated with Nafcillin for 6 weeks. She was discharged and over the next few weeks she followed up with her primary care doctor. A repeat echocardiogram in 6 weeks did not reveal any vegetations. DISCUSSION: TEE is recommended in patients with high clinical suspicion of IE and a negative or nondiagnostic TTE (transthoracic echocardiogram). The sensitivity of TEE for vegetation is approximately 96 percent for native valves and 92 percent for prosthetic valves, and the specificity for both is approximately 90 percent. Therefore the question arises whether we should continue treatment for IE if TEE is negative? As in this case, clinical suspicion of IE may persist after a negative TEE. Potential sources of false-negative TEE studies include vegetation’s that are smaller than the limits of resolution, previous embolization of vegetation, or inadequate views to detect small abscesses. Accurate differentiation between true vegetation’s and other IE-related changes, such as ruptured chordae, is frequently difficult. It is also important to emphasize that there are blind spots with TEE. CONCLUSIONS: When clinical suspicion of IE is high and the TEE results are negative, a repeat TEE study is warranted within 7 to 10 days, which may demonstrate previously undetected vegetations or abscesses. Even if a TEE is negative, treatment is warranted if clinical suspicion is high. Reference #1: Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2015;36:3075. Reference #2: Shively BK, Gurule FT, Roldan CA, Leggett JH, Schiller NB. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol. 1991;18:391-397. DISCLOSURE: The following authors have nothing to disclose: Mouzamjha Faroqui, Amal Shariff No Product/Research Disclosure Information

Cerebrovascular Accident in a Young Patient With Infective Endocarditis With Known Mitral Valve Vegetation, Patent Foramen Ovale, and DVT: An Anticoagulation Conumdrum; a Case Report

SESSION TITLE: Nervous System Disorders in the ICU 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: This is case of a young patient who presented with a cerebrovascular accident (CVA) in the presence of a patent foramen ovale (PFO), a deep venous thrombosis (DVT), and infective endocarditis (IE) with known vegetation on the mitral valve (MV). The need for anticoagulation in this setting was unclear as the etiology of the CVA may have been thrombotic or septic. CASE PRESENTATION: 29 year old female with a history of intravenous drug use, IE with Streptococcus bacteremia, and MV vegetation was admitted for CVA symptoms and subsequent unresponsiveness and hypoxia prompting intubation. The patient was receiving Rocephin for IE as an outpatient and was scheduled to have MV repair due to severe MV regurgitation. The patient presented prior to the scheduled MV repair with a CVA from an unknown etiology as the patient had a PFO, DVT, and IE with vegetation that was 1.2 cm in diameter. CT head did not show hemorrhage or old infarction. MRA head showed occlusion of the left MCA 7-10 mm beyond the bifurcation of the left ICA. Brain MRI showed probable 5-6 mm long embolus in proximal left MCA and infarction of the caudate nucleus and putamen without hemorrhage. Given thrombocytopenia, patient was not a good candidate for tPA. Neurosurgery did not recommend intervention. The patient did not receive anticoagulation. The family chose comfort measures and hospice. DISCUSSION: Current standard treatment for IE is against routine anticoagulant and antiplatelet therapy, unless a separate indication exists. Neurological complications (intracerebral infarction and hemorrhage) are a major determinant of poor outcome in IE.1 Mortality rates with CVA can reach up to 50% and worse prognosis if aortic and MV are involved with Staphylococcus aureus bactermia.4 The mechanisms of brain hemorrhage have been related to ruptured mycotic aneurysms, arterial rupture due to arteritis, and hemorrhagic transformation of an ischemic infarction. Mortality was higher in patients with prosthetic valve IE on anticoagulation than in naïve valve IE without anticoagulation (71% vs 37%; P=0.02) due to CNS complications.4 However, others reported the incidence of CNS complications and mortality were higher if anticoagulant therapy was discontinued.3 There was no difference in the number of CNS complication among those with and without anticoagulation, and the probability of these complications rapidly decreases after antimicrobial therapy has been started.2 CONCLUSIONS: There are currently no direct guidelines when to anticoagulate patients with concurrent IE/PFO/CVA/DVT. Anticoagulation will need to be individualized, remain within therapeutic range, along with frequent serial use of CT/MRI scan and clinical signs to decrease the frequency and severity of CNS complications.8 Reference #1: Delahaye JP. et al. Cerebrovascular accidents in infective endocarditis: role of anticoagulation. European Heart Journal (1990) 11, 1074-1078 DISCLOSURE: The following authors have nothing to disclose: Jennifer Treece, Vandana Pai, Kim Phung Nguyen, Girendra Hoskere No Product/Research Disclosure Information

Minimally Invasive Mitral Valve Surgery for Mitral Valve Infective Endocarditis.

The feasibility of minimally invasive mitral valve (MV) surgery in infective endocarditis (IE) has not been reported in detail. We assessed the safety, efficacy, and durability of the minimally invasive approach through a right anterolateral minithoracotomy for surgical treatment of MV IE. A review of the Leipzig Heart Center database revealed 92 eligible patients operated on between 2002 and 2013. All patients had undergone minimally invasive surgery for IE. The indication for surgery was isolated IE of the MV in all patients. Baseline and intraoperative data, as well as clinical outcomes and short-term follow-up were analyzed retrospectively. The patients' mean age was 60.9 ± 15.3 years, the logistic EuroSCORE II was 19.6 ± 19.1%, and 64.1% (59) were male. MV repair was feasible in 23.9% (22/92) of patients. Repair techniques included annuloplasty ring implantation, anterior mitral leaflet resection, posterior mitral leaflet resection, and implantation of neochordae. MV replacement was performed in 69 patients (75%), a mitral annulus patch in 1 patient, and concomitant tricuspid valve surgery for tricuspid regurgitation in 5 patients. Bacteriological analysis showed staphylococcus infection in 45.5%, streptococcus in 36.4%, enterococcus in 13.6%, and others in 4.5%. The 30-day-mortality rate was 9.8% (9 patients). The 1-year follow-up showed a 1-year survival rate of 77.7 ± 4.4% and freedom from reoperation within 1 year due to reendocarditis of 93.3 ± 2.1%. The minimally invasive approach is suitable for the treatment of IE of the MV. It is a good technique in IE in selected patients.

Surgery for Infective Endocarditis: Outcomes and Predictors of Mortality in 360 Consecutive Patients.

BackgroundA retrospective analysis was conducted of the early and long-term outcomes after surgery for infective endocarditis (IE).Material/MethodsWe included 360 patients with IE operated upon between 1993 and 2012. The primary endpoint was overall cumulative postoperative survival at 30 days. Secondary endpoints were early postoperative outcomes and complication rates. Factors associated with 30-day mortality were analyzed.ResultsMean age was 58.7±14.7 years and 26.9% (n=97) were female. The mean follow-up was 4.41±4.53 years. Postoperative survival was 81.7% at 30 days, 69.4% at 1 year, 63.3% at 5 years, and 63.3% at 10 years. Non-survivors were significantly older (p=0.014), with higher NYHA Class (p=0.002), had higher rates of preoperative diabetes mellitus (p=0.005), renal failure (p=0.001), and hepatic disease (p=0.002). Furthermore, non-survivors had higher baseline alanine aminotransferase (ALT, p=0.048), aspartate transaminase (AST, p=0.027), bilirubin (p=0.013), white cell count (WCC, p=0.034), and CRP (p=0.049). Factors associated with 30-day mortality were longer duration of surgery, CPB, and aortic cross-clamping times (p<0.001, p<0.001, and p=0.003, respectively), as well as higher RBC, FFP, and platelet transfusion requirements (p<0.001, p=0.005, and p<0.001, respectively). Multivariate logistic regression analysis revealed liver cirrhosis (OR 4.583, 95-CI: 1.096–19.170, p=0.037) and longer CPB time (OR 1.025, 95-CI 1.008–1.042, p=0.004) as independent predictors of 30-day mortality.ConclusionsSurgical treatment of IE shows satisfactory early, midterm, and long-term results. Multivariate logistic regression analysis revealed cirrhosis and longer CPB time as independent predictors of 30-day mortality.

Infective Endocarditis in a Regional Hospital – 10-year Analysis in Izola General Hospital

Introduction : Infective endocarditis (IE) is a serious disease with a high mortality rate and is defned as an inflammation of the endocardium, caused by microorganisms. Most data about IE originate from referral hospitals, therefore we aimed to analyse the demographics, presentation, diagnostics, treatment and outcome of IE at a regional hospital (Izola General Hospital–SBI) in a 10-year period. Methods : We analysed 51 episodes of IE and compared patients who were treated at a regional hospital alone, to those transferred to a referral centre. We also included data about all IE patients in a large referral hospital (University Medical Centre Ljubljana–UMCL). Results : Gender and age of the patients in SBI were similar to UMCL patients, however, there was a slightly higher share of IE in drug users and lower of prosthetic valve endocarditis. Our patients more often had streptococcal and less often staphylococcal endocarditis. Fewer patients needed surgery and time to operation was 17 days (median). Twenty-six percent of the patients died in the hospital. Approximately a half of the patients were transferred to a referral hospital, more often younger patients and women. The transferred patients often underwent surgery. Conclusions : Good cooperation with a referral hospital ensures that the outcome and other data of IE patients treated at a regional hospital are comparable to those in the literature. Some differences between patients treated in the regional hospital and the referral centre were observed. Time from admission to surgery could be shortened.

Infekcijski endokarditis v regionalni bolnišnici – Analiza primerov v letih 2005–2014

Introduction: Infective endocarditis (IE) is a serious disease with a high mortality rate and is defned as an inflammation of the endocardium, caused by microorganisms. Most data about IE originate from referral hospitals, therefore we aimed to analyse the demographics, presentation, diagnostics, treatment and outcome of IE at a regional hospital (Izola General Hospital–SBI) in a 10-year period.Methods: We analysed 51 episodes of IE and compared patients who were treated at a regional hospital alone, to those transferred to a referral centre. We also included data about all IE patients in a large referral hospital (University Medical Centre Ljubljana–UMCL).Results: Gender and age of the patients in SBI were similar to UMCL patients, however, there was a slightly higher share of IE in drug users and lower of prosthetic valve endocarditis. Our patients more often had streptococcal and less often staphylococcal endocarditis. Fewer patients needed surgery and time to operation was 17 days (median). Twenty-six percent of the patients died in the hospital. Approximately a half of the patients were transferred to a referral hospital, more often younger patients and women. The transferred patients often underwent surgery.Conclusions: Good cooperation with a referral hospital ensures that the outcome and other data of IE patients treated at a regional hospital are comparable to those in the literature. Some differences between patients treated in the regional hospital and the referral centre were observed. Time from admission to surgery could be shortened.

Evaluation of daptomycin combinations with cephalosporins or gentamicin against Streptococcus mitis group strains in an in vitro model of simulated endocardial vegetations (SEVs)

Among viridans group streptococcal infective endocarditis (IE), the Streptococcus mitis group is the most common aetiological organism. Treatment of IE caused by the S. mitis group is challenging due to the high frequency of β-lactam resistance, drug allergy and intolerability of mainstay antimicrobial agents such as vancomycin or gentamicin. Daptomycin has been suggested as an alternative therapeutic option in these scenarios based on its excellent susceptibility profile against S. mitis group strains . However, the propensity of many S. mitis group strains to rapidly evolve stable, high-level daptomycin resistance potentially limits this approach. We evaluated the activity of 6 mg/kg/day daptomycin alone or in combination with gentamicin, ceftriaxone or ceftaroline against two daptomycin-susceptible S. mitis group strains over 96 h in a pharmacokinetic/pharmacodynamic model of simulated endocardial vegetations. Daptomycin alone was not bactericidal and high-level daptomycin resistance evolved at 96 h in both organisms. Combinations of daptomycin + ceftriaxone and daptomycin + ceftaroline demonstrated enhanced killing activity compared with each antibiotic alone and prevented emergence of daptomycin resistance at 96 h. Use of gentamicin as an adjunctive agent neither improved the efficacy of daptomycin nor prevented the development of daptomycin resistance. Addition of ceftriaxone or ceftaroline to daptomycin improves the bactericidal activity against S. mitis group strains and prevents daptomycin resistance emergence. Further investigation with combinations of daptomycin and β-lactams in a large number of strains is warranted to fully elucidate the clinical implications of such combinations for treatment of S. mitis group IE.