Treatment Of Infective Endocarditis Research Articles

Epidemiology of infective endocarditis in Hong Kong, 2000–2019

Abstract Background/Introduction Despite improvements in diagnostic and therapeutic strategies, the mortality and morbidity of infective endocarditis (IE) remain high. The incidence, outcomes, and surgical intervention of IE, particularly in an Asian population, are poorly understood and characterised, and the effect of antibiotic prophylaxis guidelines revision on the incidence of IE remains unexplored. Purpose We aim to describe temporal changes in the epidemiology and surgical intervention for IE in Hong Kong in the past 2 decades. Methods From a well-validated territory-wide database in Hong Kong, all patients aged 20 or above diagnosed with incident IE from 2000–2019 were included. The temporal trends in the incidence of IE, rate of surgical intervention, and mean Charlson Comorbidity Index (CCI) were characterised using Poisson regression analysis and expressed in annual percentage change (APC [95% CI]). Interrupted time series analysis was used to evaluate the change in incidence after the revision of antibiotic prophylaxis guidelines. The association between surgical intervention and mortality was evaluated using propensity score analytics. Temporal trends in 1-year all-cause mortality were evaluated using multivariable Cox regression. Results A total of 5,657 patients (59.9±18.3 years, 37.2% females) were included. The crude incidence remained was stable from 2000 to 2019 (APC 0.1% [−0.5 to 0.7], P=0.675), and remained unchanged following the revision of antibiotic prophylaxis guidelines in 2008 (relative risk of change 0.90 [0.64 to 1.00], P=0.065) (Figure 1). Concordant with an increase in the mean age of IE patients (APC 0.9% [0.8 to 1.1], P<0.001), the comorbidity burden grew substantially from 2000 (CCI 0.55±1.27) to 2019 (CCI 1.09±1.66). The rate of surgical intervention significantly increased from 5.3% in 2000 to 17.8% in 2019 (APC 2.7% [1.1 to 4.3], P=0.004), and surgical intervention at 1 year was associated with a 45% risk reduction in 1-year all-cause mortality (Hazard Ratio 0.55 [0.46 to 0.65], P<0.001). Nevertheless, the crude all-cause mortality rate at 1 year increased from 27.4% in 2000 to 31.5% in 2019, with no significant trend after adjustment for demographics and comorbidities (APC −0.7% [−1.6 to 0.1], P=0.087). Conclusions In this large cohort of Asian patients, the incidence of IE remained static and did not change following the revision of antibiotic prophylaxis guidelines. Over time, patients with IE have evolved to be older and more comorbid. Despite an increasing rate of surgical intervention that conferred improved survival, the mortality of IE remained irresistibly high. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): The Shenzhen Key Medical DisciplineThe Sanming Project of HKU-SZH Cardiology

The impact of establishing a regional infective endocarditis (IE) network on pre-operative IE-related complications and on post-operative outcome

Abstract Background Infective endocarditis (IE) requires a high degree of suspicion and advanced level of multidisciplinary management. In 2015, the European guidelines recommended the formation of an endocarditis-team (ET) for optimal treatment of IE. In 2011, we already established an ET within the hospital that was only consulted on demand for certain patients. Since 2015, ET has been increasingly involved in the management of almost all patients with IE. In addition, we established in 2015 a statewide endocarditis- (E) network for the referring hospitals. Purpose We investigated the effect of E-network on reducing referral latency and pre-operative IE-related complications. We also investigated the adherence to the ET management recommendations in our hospital and its impact on post-operative stroke and mortality. Methods We retrospectively analyzed data from patients operated for IE in our center between 01/2007 and 03/2018. We conducted univariate analysis using Chi-square or Fisher's exact test, Multivariate logistic regression models for in-hospital mortality and post-operative stroke, and Kaplan-Meier estimate of 5-years survival. Results Among 630 patients operated for IE in our center, 409 (65%) underwent surgery in the 1st era before 12/2014. S. aureus IE was more frequent in the second era (34% vs 25%, p<0.001). The median time from the onset of symptoms to referral in the 2nd era was halved compared to the first one [7 days (IQR 2–19) vs 15 days (IQR 6–35)]. Patients in the 2nd era were admitted with less IE-related complications, i.e. less preoperative stroke (14% vs 27%, p<0.001), less heart failure (45% vs 69%, p<0.001) less cardiac abscesses (24% vs 34%, p=0.018), less acute renal insufficiency requiring hemodialysis (8% vs 14%, p=0.026). The lack of ET management recommendations was an independent predictor for in-hospital mortality (adjusted OR: 2.13, 95% CI: 1.27–3.53, p=0.004) and post-operative stroke (adjusted OR: 2.23, 95% CI: 1.12–4.39, p=0.02), and was associated with worse 5-years survival (59% compared to 40%, log rank<0.001). Conclusion Endocarditis-network led to earlier referral of patients, which resulted in less IE-related complications on admission. Lack of ET management recommendations was an independent predictor for post-operative stroke, in-hospital mortality and was associated with worse 5-years survival. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Clinical predictors of outcome in patients with infective endocarditis receiving outpatient parenteral antibiotic therapy (OPAT)

Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat infective endocarditis (IE) with documented success. This study aims to identify risk factors for treatment failure and poor outcomes in patients with IE treated through OPAT. We conducted a retrospective analysis of all episodes of IE treated over 13 years (September 2006 - September 2019) at a large teaching hospital in Sheffield, UK. We defined OPAT failure as unplanned readmission or death within 30 days of discharge from the OPAT service. Major adverse cardiac events (MACE) were defined as a composite of IE-related death, cardiac surgery, and recurrence of IE within the first year of completion of OPAT. Overall, 168 episodes of IE were reviewed. OPAT failure and MACE occurred in 44 episodes (26.2%) and 29 episodes (17.3%) respectively. On multivariable analysis, pre-existing renal failure (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.08-8.30; P=0.034) and Charlson comorbidity score (aOR, 1.29 per unit increase; 95% CI, 1.06-1.57; P=0.011) were associated with increased risk of failure. Previous endocarditis (aOR, 3.60; 95% CI, 1.49-8.70; P=0.004) and cardiac complications (aOR, 3.85; 95% CI, 1.49-9.93; P=0.005) were risk factors for MACE, whereas cardiac surgery during the initial hospitalisation for IE (aOR, 0.34; 95% CI, 0.12-0.22; P<0.001) was a protective factor. Our findings suggest that OPAT is safe and effective for completing antibiotic treatment for IE, including cases deemed to be at increased risk of complications. However, careful patient selection and monitoring of patients with pre-existing comorbidities and cardiac complications are recommended to optimise clinical outcomes.

ANTIMICROBIAL ACTIVITY OF DALBAVANCIN AGAINST GRAM-POSITIVE BACTERIA ISOLATED FROM PATIENTS WITH INFECTIVE ENDOCARDITIS FROM THE UNITED STATES AND EUROPE (2016-2020): RESULTS FROM THE INTERNATIONAL DALBAVANCIN EVALUATION OF ACTIVITY (IDEA) PROGRAM

TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: The management of infective endocarditis (IE) requires aggressive and prolonged antimicrobial treatment. Dalbavancin (DALBA) has demonstrated potent in vitro activity against gram-positive (GP) organisms commonly responsible for IE and is being evaluated for treatment of complicated bacteremia and IE. METHODS: 16,164 GP organisms were consecutively collected from patients with bloodstream infections (BSIs) in the United States (US; 8,807 isolates from 79 hospitals) and Europe (EU; 7,357 isolates from 42 hospitals in 20 countries) from 2016 to 2020 via the IDEA Program. The collection included 323 isolates from patients with a diagnosis of IE. Isolates were tested for susceptibility (S) against DALBA and comparators by the CLSI broth microdilution method. RESULTS: Among IE isolates, the most common organisms were S. aureus (SA; 52.3%), E. faecalis (EF; 18.0%), and viridans group streptococci (VGS; 10.8%). Among BSI isolates, the most common organisms were SA (45.0%), β-hemolytic streptococci (BHS; 11.0%), and EF (10.8%). DALBA and daptomycin (DAPTO) showed complete activity (100.0%S) against SA from IE, but MIC values from DALBA (MIC50/90, 0.03/0.03 mg/L) were 8- to 16-fold lower than DAPTO (MIC50/90, 0.25/0.5 mg/L). Against SA from IE, linezolid (LZD) and teicoplanin (TEI) were active against 100.0% of isolates and ceftaroline was active against 99.0% of isolates. Vancomycin (VAN) inhibited 98.8% of isolates at ≤1 mg/L. Methicillin-resistant SA (MRSA) rates were 43.3% (US) and 27.5% (EU) among SA from IE (n=169), and 41.1% (US) and 24.0% (EU) among SA from BSI (n=7,279). All EF isolates from IE were S to ampicillin and LZD, whereas 98.3% were S to DALBA (MIC50/90, 0.03/0.06 mg/L), DAPTO (MIC50/90, 0.5/1 mg/L), VAN (MIC50/90, 1/2 mg/L), and TEI (MIC50/90, ≤0.5/≤0.5 mg/L). Against EF, DALBA MIC values were 16- to 32-fold lower than DAPTO and VAN. Among EF from BSI (n=1,748), S to DALBA, DAPTO, and VAN was 98.0%, 99.5%, and 97.7%, respectively. All VGS isolates from IE (n=35) were S to DALBA (at ≤0.12 mg/L), VAN, and LZD; 96.6% of VGS were S to DAPTO. All coagulase-negative staphylococci from IE were S to DALBA (MIC50/90, 0.03/0.12 mg/L; highest MIC, 0.12 mg/L), DAPTO (MIC50/90, 0.25/0.5 mg/L), VAN (MIC50/90, 2/2 mg/L), and LZD (MIC50/90, 1/1 mg/L). E. faecium (EFM) was isolated from 5.6% of IE cases. Among EFM isolates from IE, 66.7% were S to VAN and 72.2% were inhibited at ≤0.12 mg/L of DALBA. BHS was S to DALBA (highest MIC, 0.03 mg/L) and most antimicrobial agents tested. CONCLUSIONS: DALBA exhibited potent in vitro activity against a large collection of contemporary GP isolates recovered from patients with BSI, including IE, in US and EU medical centers. CLINICAL IMPLICATIONS: Due to its prolonged half-life and high potency against GP, DALBA may represent a valuable option for treatment of IE. These results support further investigations on the role of DALBA in the treatment of BSI and IE. DISCLOSURES: my employer received research support relationship with AbbVie Please note: 2020-2022 Added 04/20/2021 by Cecilia Carvalhaes, source=Web Response, value=Grant/Research Support No relevant relationships by Mariana Castanheira, source=Web Response no disclosure on file for Rodrigo Mendes;Research Contractor relationship with Allergan Please note: $1001 - $5000 by Helio Sader, source=Web Response, value=Grant/Research Support Research Contractor relationship with AbbVIe (formerly Allergan) Please note: Ongoing Added 04/15/2021 by Helio Sader, source=Web Response, value=Grant/Research Support No relevant relationships by Streit Streit, source=Web Response

A RARE CASE OF SUCCESSFUL TREATMENT OF PROSTHETIC MITRAL VALVE INFECTIVE ENDOCARDITIS WITH A NONSURGICAL APPROACH

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis (IE) is an infection of the endocardial surface of the valve, native or prosthetic. Primary treatment for IE involving a prosthetic valve is surgical intervention (1, 2) and if left untreated can be fatal. Incidence rate of deaths associated with IE is 4.6/100,000/year (1). We present a case of a 64-year-old male who was successfully treated medically without any surgical intervention for prosthetic mitral valve IE. CASE PRESENTATION: This is a 64-year-old male with known past medical history of aortic valve replacement, tricuspid and mitral valve repair, atrial fibrillation status post cardioversion and ablation, and hypertension who complained of fevers, palpitations, and dyspnea for a day. He was started on vancomycin and piperacillin-tazobactam pending blood cultures. The initial and repeat blood cultures were positive for methicillin sensitive Staphylococcus aureus (MSSA) and the antibiotics were switched to nafcillin. Due to persistent bacteremia, transesophageal echocardiography (TEE) was recommended which showed filamentous echodensity on the mitral annuloplasty ring. Patient had an allergic reaction to nafcillin therefore on discharge antibiotics were switched to Ceftriaxone 2 gm intravenously (IV) and Daptomycin 600 mg IV daily for 6 weeks. TEE was repeated six weeks later, which showed no vegetations or abscesses. DISCUSSION: Cases of IE caused by Staphylococcus aureus are 'almost always surgical diseases,' according to the American Heart Association/American College of Cardiology/American Thoracic Society guidelines for the management of valvular heart disease (2). Since this patient refused surgery after having multiple heart surgeries in the past, the risks/benefits of surgery needed to be carefully evaluated. Daptomycin and Ceftriaxone were used because Daptomycin exerts rapid bactericidal activity against S. aureus, including strains tolerant or resistant to other agents. When used in combination with Daptomycin, Ceftriaxone improves bactericidal activity through synergistic effects. There is evidence that rapid bacterial killing has potential clinical advantages over bacteriostatic therapy in certain infections (3). The combination of beta lactams with Daptomycin also have an effect on enhanced bacterial clearance (3). This case report provides evidence that medical therapy is a viable alternative to surgical treatment. To our knowledge, this is the first report of successful treatment of prosthetic mitral valve infective endocarditis with a non-surgical approach. CONCLUSIONS: With the correct combination of antibiotics and routine follow up, non surgical candidates can be managed medically. While conclusions can be made based on the improvement and clearance of bacteremia of this patient, future studies are needed to strengthen evidence showing the benefit of medical treatment over surgical approaches for prosthetic valve endocarditis. REFERENCE #1: Cresti A, Chiavarelli M, Scalese M, et al. Epidemiological and mortality trends in infective endocarditis, a 17-year population-based prospective study. Cardiovasc Diagn Ther. 2017;7(1):27-35. REFERENCE #2: Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Valvular Heart Disease). Circulation 2008;2013:e523–661. REFERENCE #3: Dhand A, Bayer AS, Pogliano J, et al. Use of antistaphylococcal beta-lactams to increase daptomycin activity in eradicating persistent bacteremia due to methicillin-resistant Staphylococcus aureus: Role of enhanced daptomycin binding.Clin Infect Dis 2011;53:158-163. DISCLOSURES: No relevant relationships by Dilesha Kumanayaka, source=Web Response No relevant relationships by Richard Miller, source=Web Response No relevant relationships by monica mutyala, source=Web Response No relevant relationships by Fayez Shamoon, source=Web Response Speaker/Speaker's Bureau relationship with Gilead Please note: $5001 - $20000 by jihad slim, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with ViiV Please note: $5001 - $20000 by jihad slim, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Abbvie Please note: $5001 - $20000 by jihad slim, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with merck Please note: $5001 - $20000 by jihad slim, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Jansen Please note: $5001 - $20000 by jihad slim, source=Web Response, value=Honoraria

Infective Endocarditis in Patients with Hypertrophic Cardiomyopathy

A literature review is presented, reflecting the incidence, etiology, hemodynamics, localization, clinical manifestations, outcomes and treatment of infective endocarditis (IE) in patients with hypertrophic cardiomyopathy (HCM). Despite the relative rarity of IE in patients with HCM, the combination of these pathologies is characterized by mutual aggravation and poor prognosis. The addition of IE increases the risk of death in patients with obstructive HCM, deteriorating circulatory disorders, increasing the likelihood of uncontrolled sepsis and embolism. Conservative treatment of IE in patients with HCM does not differ from that without HCM. Interdisciplinary interaction is needed in the management of patients with IE against the background of HCM in determining the indications for cardiac surgery and choosing the optimal method. Antibacterial prophylaxis of IE before invasive medical manipulations in patients with HCM is not recommended by the current consensus documents, however, the decision for each patient should be made individually, with a mandatory assessment of the risk of IE, the severity of hemodynamic disorders and prognosis.

An Experimental Infective Endocarditis Model in Rats

OBJECTIVE: Infective endocarditis (IE) is defined as infection of the endocardial surface of the heart. Updates are needed in the diagnosis and treatment of IE, as well as in animal models of IE. Based on this need, a new model of infective endocarditis induced by S. aureus was described in our study.&#x0D; METHODS: This study was performed on 7 Wistar albino male rats, each aged six months and weighing 250-300 g. Underwent the surgical implantation of a 20 G catheter, to gain access to right common carotid artery. Twenty-four hours after implantation, 0.5 ml 100.000 colony forming unit (cfu) of S. aureus was injected via the tail vein and 3 days later echocardiography was performed and rats subsequently sacrificed. IE was later diagnosed histopathologically.&#x0D; RESULTS: Two of the rats were exitus one day after S. auerus was given. The mortality rate of the experiment was 28.5%. Histopathological examination revealed vegetations and bacterial colonization were detected in the endocardium in all rats that protruded from the endocardium to the cardiac cavity.&#x0D; CONCLUSION: Our study is the first study in the literature to identify the IE rat model using the 20 G catheter. Due to the practical application of the surgical procedure (use of 20 G catheter) in our study, we think that it will provide much convenience to the researchers in the experimental research on IE diagnosis and treatment.

Surgical treatment of infective endocarditis at comprehensive versus primary valve centers

BackgroundA recent expert consensus statement proposed designation of comprehensive and primary valve centers, with a recommendation that comprehensive centers house surgical skill and resources to treat patients with infective endocarditis (IE). We sought to compare outcomes of patients who underwent valve surgery for IE at comprehensive versus primary valve centers within a large health care system. MethodsWe reviewed 513 consecutive patients who underwent IE surgery at 8 hospitals (2 comprehensive and 6 primary valve centers) from 2014 to 2020. Outcomes from comprehensive and primary valve centers were compared after propensity score matching on the basis of patient characteristics, valve involvement, valve type, and IE treatment status. Multivariate logistic regression was used to identify risk factors for operative mortality. ResultsPropensity score matching generated comparable groups with similar mean Society of Thoracic Surgeons/Gaca IE risk scores among comprehensive and primary valve center cohorts. Comprehensive valve centers were more likely to perform the Bentall procedure (60.4% vs 21.7%; P < .01) when aortic root abscess was present and mitral valve repair (50.4% vs 26.3%; P < .01) in cases of mitral valve involvement. Operative mortality was significantly lower at comprehensive valve centers (6.2% vs 13.0%; P = .04), and multivariate logistic regression suggested that surgery at comprehensive valve centers was protective against operative mortality (odds ratio, 0.39; 95% confidence interval, 0.17-0.88; P = .02). Similar findings were present in a sensitivity analysis limited to patients with active IE only. ConclusionsAn increased risk for operative mortality was associated with surgery performed at primary valve centers compared with comprehensive valve centers. Referral or transfer of patients with IE and surgical indications to comprehensive valve centers should be considered.

Zolpidem improves patients' sleep quality after surgical treatment for infective endocarditis: a prospective observational study.

The objective of this study was to investigate the efficacy of zolpidem for improving post-operative sleep quality among patients with infective endocarditis (IE) and to identify the potential risk factors for impaired sleep quality at 6months after surgery. Patients withIE who underwent surgical treatment were divided into two groups according to zolpidem usage. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to evaluate patients' sleep qualityand daytime sleepiness at baseline, which was the second day after transferal, and at 6months after surgery. Logistic regression was used to identify potential risk factors. There were 32 patients in the zolpidem group and 42 in the control group. The PSQI and ESS scores at 6months after surgery were significantly lower than those at baseline in both groups (P = 0.04). Additionally, 9 patients (28%) in the zolpidem group and 22 patients (52%) in the control group suffered poor sleep quality. Multivariate analysis identified age (odds ratio [OR] = 1.26, 95% confidence interval [CI]: 1.12-1.42), baseline PSQI score (OR = 2.66, 95%CI: 1.55-4.65), and no zolpidem usage (OR = 45.48, 95%CI: 3.01-691.23) as independent factors for poor sleep quality. Poor sleep quality after IE surgery was prevalent among patients even 6months after IE surgery. Age, baseline PSQI score and no zolpidem usage were independently associated with poor sleep quality. Therefore, zolpidem has the potential to be an effectivepart of a treatmentarsenal for poor sleep quality after surgical treatment for IE.

Surgical treatment for active infective endocarditis: progress and challenges

<p indent=0mm>Infective endocarditis (IE) is a challenging disease. In the past century, it has the highest mortality among all kinds of valvular heart diseases. Treatment for IE has developed over time from anti-infective therapy only to today’s active surgery. However, due to its characteristics of multisystem involvement and changeable clinical symptoms, early diagnosis, indication and timing of surgery, and evaluation of surgical risk remain urgent issues at present. By reviewing representative literature in the past <sc>20 years</sc> and combining them with our experience of surgical treatment for IE, we summarize the latest progress and challenges faced by active surgery for IE, and emphasize the importance of establishing IE multidisciplinary team in clinical practice.

Analysis of sex differences in the clinical presentation, management and prognosis of infective endocarditis in Spain

IntroductionSex-dependent differences of infective endocarditis (IE) have been reported. Women suffer from IE less frequently than men and tend to present more severe manifestations. Our objective was to analyse the...

Prosthesis choice for surgical treatment of left-sided native valve infective endocarditis: Determinants and impact on outcomes

Surgical treatment is required in approximately half of the patients with infective endocarditis (IE) because of severe complications. To date there is no recommendation favoring a specific valve substitute for IE treatment and accordingly there is a wide variation in routine surgical management of these patients. The purpose of this study is to describe surgical practices in our center and to investigate the impact on clinical outcomes. All patients with native valve left-sided IE, who underwent valve replacement surgery with a mechanical or biological prosthesis in our institution between 1 January 2006 and 31 December 2018 were enrolled in this retrospective study. A total of 303 patients were included (mean age = 58 years, 80% men). Patients in whom a biological valve was chosen (64%, n = 194) were older and had more comorbid conditions compared to patients who received a mechanical valve (36%, n = 109). In hospital mortality was respectively 19% ( n = 36) in the bioprosthesis group avec 3% ( n = 3) in the mechanical valve group ( P < 0.0001). The mortality rates at 1 and 3 years were 35% and 41% in the biological valve group, these rates were 8% and 15% in the mechanical valve group. Factors associated to in hospital and mid term mortality were age, comorbid conditions, hemodynamic failure, a double valve replacement or associated bypass surgery. The type of the implanted valve substitute was not independently associated with mortality. For surgical management of IE, a biological valve is the most used valve substitute in our institution. Mechanical valves seem to be implanted in a very selected and low-risk patient subgroup. The valve substitute does not appear to be related to in hospital nor to midterm mortality rates.

Malassezia restricta: An Underdiagnosed Causative Agent of Blood Culture-Negative Infective Endocarditis.

Infective endocarditis (IE) is a severe disease requiring microbial identification to successfully adapt its treatment. Currently, identification of its etiological microorganism remains unresolved in 5.2% of cases. We aimed to improve IE diagnosis using an ultra-sensitive molecular technique on cardiac samples in microbiologically nondocumented (culture and conventional polymerase chain reaction [PCR]) IE (NDIE) cases. Cardiac samples explanted in a tertiary hospital in Lyon, France, from patients with definite IE over a 5-year period were retrospectively analyzed. NDIE was defined as Duke definite-IE associated with negative explorations including cardiac samples culture, bacterial amplification, and serologies. Ultrasensitive molecular diagnosis was achieved using the Universal Microbe Detection kit (Molzym®). Fungal identification was confirmed using 26S-rDNA and internal transcribed spacer amplifications. Fungal infection was confirmed using Grocott-Gromori staining, auto-immunohistochemistry on cardiac samples, and mannan serologies. Among 88 included patients, microbial DNA was detected in all 16 NDIE cases. Bacterial taxa typical of IE etiologies were detected in 13/16 cases and Malassezia restricta in the 3 other cases. In these 3 cases, histological examination confirmed the presence of fungi pathognomonic of Malassezia that reacted with patient sera in an auto-immunohistochemistry assay and cross-reacted with Candida albicans in an indirect immunofluorescent assay. M. restricta appears to be an underestimated causative agent of NDIE. Importantly, serological cross-reaction of M. restricta with C. albicans may lead to its misdiagnosis. This is of major concern since M. restricta is intrinsically resistant to echinocandins; the reference treatment for Candida-fungal IE.

Surgical treatment for infective endocarditis in the ageing society: a nationwide retrospective study in Japan

ObjectiveThe current status of surgical treatment for infective endocarditis (IE) among very elderly people is unclear.MethodsWe extracted data on patients in Japan with community-acquired IE who were admitted and discharged...

Surgical therapy of infective endocarditis following interventional or surgical pulmonary valve replacement.

Percutaneous pulmonary valve prostheses and right ventricle-to-pulmonary artery conduits are at risk for infective endocarditis (IE). In children and adults with a congenital heart disease, a pulmonary valve implant is frequently necessary. Prosthetic valve endocarditis is a conservatively barely manageable, serious life-threatening condition. We investigated the results of surgical pulmonary valve replacements in patients with IE. A total of 20 patients with congenital heart disease with the definite diagnosis of IE between March 2013 and July 2020 were included in this single institutional, retrospective review. Infected conduits were 11 Melody, 5 Contegra, 3 homografts and 1 Matrix P Plus. All of the infected prosthetic material was removed from the right ventricular outflow tract up to the pulmonary bifurcation. Pulmonary homografts were implanted after pulmonary root resection as right ventricle-to-pulmonary artery conduits. All patients survived and were discharged infection-free. The mean time from the conduit implant to the operation for IE was 4.9 years [95% confidence interval (CI), 3.0-6.9]. The median intensive care unit stay was 3.0 days (95% CI, 2.0-4.7), and the median hospital time was 25.0 days (95% CI, 19.2-42.0). Median follow-up time was 204.5 days (range 30 days to 5 years) without death or recurrent endocarditis. The surgical treatment of IE of percutaneous pulmonary valve prostheses and right ventricle-to-pulmonary artery conduits is a safe and effective therapeutic concept. Early surgical referral of patients with suspicion of IE should be pursued to avoid sequelae such as right ventricular failure, septic emboli, intracardiac expansion and antibiotic resistance.

Infective Endocarditis by Yersinia Species: A Systematic Review

Yersinia spp. are non-spore-forming Gram-negative bacilli. They comprise only three species known to cause disease in humans, namely Y. pestis, Y. enterocolitica and Y. pseudotuberculosis. Since infective endocarditis (IE) is rarely caused by Yersinia, the management of these infections can be problematic due to the lack of experience. The purpose of this study was to systematically review all published cases of IE by Yersinia species in the literature. A systematic review of PubMed, Scopus and Cochrane Library (through 1 November 2020) for studies providing epidemiological, clinical and microbiological information as well as data on treatment and outcomes of IE caused by Yersinia species was performed. A total of 12 studies, containing data of 12 patients, were included. A prosthetic valve was present in 17% of patients. The mitral valve was the most commonly infected site, followed by the aortic valve. Fever, sepsis and embolic phenomena were common clinical signs, followed by heart failure. Aminoglycosides, cephalosporins and quinolones were the most commonly used antimicrobials. Clinical cure was noted in 83%, while overall mortality was 17%. This systematic review describes IE by Yersinia and provides information on patients’ epidemiology, clinical signs and the related therapeutic strategies and outcomes.

Increased glucose variability is associated with major adverse events in patients with infective endocarditis undergo surgical treatment.

BackgroundThis study aimed to investigate the prognostic value of glucose variability (GV) in predicting postoperative major adverse events (MAEs) in patients with infective endocarditis (IE) who underwent surgical treatment.MethodsThis retrospective observational study included a total of 381 consecutive patients who underwent surgical treatment in our institution from October 2007 to August 2019. The MAEs included all-cause death, stroke, myocardial infarction, acute heart failure, IE recurrence, acute renal failure and sepsis. Postoperative GV in the first 24 hours was measured by the mean 24-hour glucose, standard deviation, coefficient of variation (CV) and mean amplitude of glycemic excursions. Univariate and multivariate logistic regression analyses were performed to identify the independent association of GV with MAEs.ResultsOf the 381 patients, 79 (20.7%) developed MAEs. The 30-day mortality of the overall study cohort was 5.23%. The multivariate logistic regression analysis indicated that 24-hour GV, measured as the CV [odds ratio (OR) =1.49, 95% CI, 1.23–3.57, P=0.012], was significantly associated with MAEs in IE patients. For every 10% increase in 24‐hour CV, there was a 49% increase in the risk of MAEs. Furthermore, compared to patients in the low tertile of GV, patients in the top tertile of 24-hour GV had a higher 30-day mortality and an increased incidence of heart failure and hemodialysis as well as longer ventilation support.ConclusionsThe results of this retrospective investigation demonstrated that increased GV measured by CV is an independent predictor of postoperative MAEs in patients undergoing surgical treatment for IE.

Infective Endocarditis with Multiple Valvar Vegetation in Uncorrected Tetralogy f Fallot: A Case Report of Rare Condition

Objective: To describe a case of an adult patient with uncorrected Tetralogy of Fallot (TOF) who suffered from Infective Endocarditis (IE) that involved the tricuspid and aortic valves. Methods: On October 2019, a-twenty-year-old male with uncorrected TOF was admitted to the emergency department of Dr. Hasan Sadikin General Hospital with a chief complaint of fever. The echocardiography showed the presence of vegetation on the tricuspid valve and aortic valve. The patient was given empirical antibiotics therapy for IE treatment. The serial blood cultures did not yield any organism growth and the transthoracic echocardiography evaluation showed healed vegetation after 21 days of antibiotics treatment. Results: A high turbulence in small VSD and valvular stenosis, as found in TOF, can injure the endocardial surface. While bacterial adherence to the injured endocardial surface can cause IE, no specific criteria available for diagnosing IE in congenital heart disease (CHD) patients compared to other population. In CHD patients, it is necessary to consider the diagnosis of IE presenting with signs of infection or fever. Our patient was known to have uncorrected TOF and was admitted to the hospital with a chief complaint of fever. The uncorrected TOF was complicated by an unusual form of aggressive vegetation involving multiple valves. Conclusion: The incidence of IE in uncorrected TOF is around 4%. Patient is advised to receive a corrective surgery for the cardiac anomaly. Surgical repair of CHD with no residual lesion reduces the risk of IE.

A Randomized Controlled Clinical Trial on Therapeutic Effects of Teicoplanin and Vancomycin after Cardiac Surgery due to MRSA infective endocarditis in ICU Patients

Background: Infective endocarditis (IE) is a relatively rare disease but with significant rates of morbidity and mortality. The goal of IE treatment is to eradicate the foci of infection, including antimicrobial therapy with or without surgery. The decision on the selection of an empirical therapy regimen is diverse and based on patient characteristics. Vancomycin and teicoplanin are bacteriostatic glycopeptide antibiotics used for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections, including MRSA-IE, and patients allergic to penicillin who are infected with methicillin-sensitive Staphylococcus aureus. Objective: The current study aimed to compare the efficacy and adverse effects of vancomycin and teicoplanin in the treatment of patients with MRSA-IE. Materials and Methods: This parallel, randomized, and controlled trial study was carried out on the efficacy and safety of teicoplanin versus vancomycin in the treatment of MRSA endocarditis within August 2012 and April 2017. The present study recruited adult patients with a definite or possible diagnosis of IE based on the Modified Duke Criteria. A central computer-generated random number list was used to allocate the patients (1:1) to the treatment with teicoplanin or vancomycin. Vancomycin was intravenously administered at a dose of 30 mg/kg/day in two doses. Teicoplanin was administered at a loading dose of 6-12 mg/kg every 12 h in four doses and then continued once a day. Results: Out of 86 patients screened with suspected IE, 66 patients were randomly assigned to the vancomycin (n=33) and teicoplanin (n=33) groups. The mean age values of the study subjects were 41±11.8 and 39±13.1 years in the vancomycin and teicoplanin groups, respectively. In addition, 27 patients (81.8%) in the vancomycin group met the criteria for microbiological cure, compared to 25 subjects (89.3%) in the teicoplanin group. In this regard, the observed difference was not statistically significant (P=0.41). Moreover, 26 (78.8%) and 23 (82.1%) patients in the vancomycin and teicoplanin groups achieved clinical cure, respectively (P=0.97). Overall, the patients in the vancomycin group experienced more adverse events in comparison to those of the teicoplanin group (P=0.04). The rate of acute kidney injury over time, especially in the first week of therapy, was higher in the vancomycin group than that reported for the teicoplanin group (P=0.05). Six and four patients in the vancomycin and teicoplanin groups required dialysis, respectively. The use of dialysis was not different between the two groups (P=0.88). Seven (21.3%) and five (17.9%) patients in the vancomycin and teicoplanin groups died, respectively, which was not statistically different between the two groups (P=0.74). Conclusions: It was concluded that the administration of vancomycin or teicoplanin does not significantly change the outcome of patients undergoing empirical treatment for MRSA-IE. This finding indicates the patients are similar in clinical outcomes and mortalities despite some adverse effects, such as skin rashes; therefore, teicoplanin can be considered a treatment choice for these diseases.

Cardiac Surgeons’ Treatment Approaches for Infective Endocarditis Based on Patients’ Substance Use History

U.S. cardiac surgeons encounter complex decision-making when treating patients with injection drug use-associated infective endocarditis (IDU-IE). We evaluated surgeons' treatment approaches for IDU-IE compared to non-IDU-IE. This is an anonymous survey of U.S. cardiac surgeons who answered hypothetical infective endocarditis (IE) clinical scenarios that varied based on patient substance use history, addiction treatment, and history of IE. Treatment approaches were classified as operative vs nonoperative. Responses were descriptively analyzed. The survey response rate was 8.7% (n = 208). Survey respondents were mostly male (85.6%) and non-Hispanic white (67.8%), but were from all regions of the United States. Surgeons reported they would operate at similar proportions for patients with native valve non-IDU-IE (63%) and IDU-IE engaged in methadone treatment (64.5%). Most surgeons reported they would operate on patients with recurrent non-IDU-IE (93.1%) compared to only 26.4% for patients with recurrent IDU-IE (P < 0.001). Most surgeons reported they would place no limits on the number of operations for patients with recurrent non-IDU-IE (73.1%), whereas 83.5% of surgeons would limit the number of surgeries for patients with recurrent IDU-IE (P < 0.001). Most respondents reported having declined to operate on patients with IDU-IE (63.5%). Cardiac surgeons are less likely to report favoring operative management for primary and recurrent infection in patients with IDU-IE, though patient engagement in methadone treatment increased the likelihood of them taking an operative approach. There is opportunity to standardize the care, including addiction treatment, of patients with IDU-IE to optimize positive short and long-term outcomes.