Treatment Of Infective Endocarditis Research Articles

SINGLE CENTER EXPERIENCE IN SURGICAL TREATMENT FOR ACTIVE ENDOCARDITIS BEFORE AND AFTER COVID–19 PANDEMIC

Abstract Background Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life–threatening condition. The impact of COVID–19 on diagnosis and outcome of surgical treatment of IE is uncertain. The aim of this study was to analyze the incidence, characteristics and outcomes of surgically treated IE before and after the COVID–19 pandemic. Methods This study retrospectively analyzed data of 536 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided in two groups depending on the date of operation: before (n=393) and after (n=142) COVID–19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied. Results We noticed a significant increase (p=0.006) in the prevalence of infective endocarditis admitted for surgery throughout the years, comparing it to overall hospitalizations in our cardiac surgery department (Figure 1). Patients from the post COVID cohort (after march 2020) had more comorbidities such as diabetes (29.6% vs 16.3% p=0.001), hypertension (71.1% vs 59.5% p=0.015), and preoperative kidney injury requiring dialysis (9.2% vs 2.5% p=0.002), but median additive and logistic Euroscore were not statistically different. In the post COVID group, we observed a greater prevalence of S. Aureus related endocarditis (24.5% vs 15.4% p=0.026), and a consequent reduction in S. non Aureus related endocarditis (12.2% vs 20.1% p=0.048) (Figure 2), a decrease of aortic valve replacement (43.0% vs 53.9%), while the number of mitral valve replacement ad repair resulted to be higher (21.1% vs 15.0% and 6.3% vs 4.3% respectively) (Figure 3). No differences in the two groups concerning early death but also death or relapse at one year after surgery. Data obtained by the multivariable analysis identify the preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality stratifying by time periods in analysis. Conclusions The incidence of surgical treated IE significant increase after COVID–19 pandemic with a higher incidence of mitral involvement instead of aortic valve. Despite the pandemic and the delay in surgical timing, results in terms of mortality and outcomes have improved and were largely unaffected by the COVID–19 pandemic.

Update on endocarditis 2024

Infective endocarditis (IE) is alife-threatening disease with an increasing incidence despite improved preventive measures. The revision of the European Society of Cardiology (ESC) guidelines on infective endocarditis in 2023 brings significant innovations in prevention, diagnostics, and treatment. Many measures for prophylaxis and prevention have been more clearly defined and given higher recommendation levels. In the diagnostics of IE the use of other imaging modalities besides echocardiography, such as cardiac computed tomography (CT), positron emission tomography (PET)/CT or single photon emission computed tomography (SPECT)/CT with radioactively labeled leukocytes was more strongly emphasized. The diagnostics and treatment of IE associated with a cardiac implantable electronic device (CIED) were also revised. An essential innovation is also the possibility of an outpatient antibiotic treatment for certain patients after initial treatment in hospital. The indications for surgery have also been revised and, in particular, the timing of surgery has been more clearly defined. This article provides an overview of the most important changes.

КЛИНИЧЕСКИЙ СЛУЧАЙ УСПЕШНОГО 120-ДНЕВНОГО КОМПЛЕКСНОГО ЛЕЧЕНИЯ ИНФЕКЦИОННОГО ЭНДОКАРДИТА МИКСОМАТОЗНО-ИЗМЕНЕННОГО МИТРАЛЬНОГО КЛАПАНА, ОСЛОЖНЕННОГО КАРДИОГЕННЫМ И СЕПТИЧЕСКИМ ШОКОМ С ПОЛИОРГАННОЙ НЕДОСТАТОЧНОСТЬЮ

Annotation. Estimated incidence of infectious endocarditis (IE) is 13.8 cases per 100.000 subjects per year while mortality as high as 0.87 death cases per 100.000 patients demonstrating upstroke trend in majority countries in the world over past 30 years. Imaging positive for IE is among major diagnostic criteria of which transthoracic echocardiography is recommended as the first-line imaging modality in suspected IE. Negative, non-diagnostic or inconclusive results of echocardiography make diagnosis of IE challenging followed by treatment delays and poor outcomes. Within current clinical case we discuss the experience of diagnosis and successful treatment of IE of mitral valve with mixomatous degeneration and rupture of chordae tendineae that challenged vegetations detection and delayed surgical treatment followed by development of complications as cardiogenic and septic shock with multiple organ failure.

Performance of the 2023 Duke-International Society of Cardiovascular Infectious Diseases Diagnostic Criteria for Infective Endocarditis in Relation to the Modified Duke Criteria and to Clinical Management-Reanalysis of Retrospective Bacteremia Cohorts.

Revised diagnostic criteria for infective endocarditis (IE), the 2023 Duke-ISCVID criteria, were recently presented and need validation. Here, we compare the 2000 modified Duke criteria for IE with Duke-ISCVID among patients with bacteremia and relate the diagnostic classification to IE treatment. We reanalyzed patient cohorts with Staphylococcus aureus, Staphylococcus lugdunensis, non-β-hemolytic streptococci, Streptococcus-like bacteria, Streptococcus dysgalactiae, Enterococcus faecalis, and HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) bacteremia. Episodes were classified as definite, possible, or rejected IE with the modified Duke and Duke-ISCVID criteria. Reclassification included the microbiology criteria, positron emission tomography-computed tomography, and cardiac implanted electronic devices. To calculate sensitivity, patients treated for IE were considered as having IE. In 4050 episodes of bacteremia, the modified Duke criteria assigned 307 episodes (7.6%) as definite IE, 1190 (29%) as possible IE, and 2553 (63%) as rejected IE. Using the Duke-ISCVID criteria, 13 episodes (0.3%) were reclassified from possible to definite IE, and 475 episodes (12%) were reclassified from rejected to possible IE. With the modified Duke criteria, 79 episodes that were treated as IE were classified as possible IE, and 11 of these episodes were reclassified to definite IE with Duke-ISCVID. Applying the decision to treat for IE as a reference standard, the sensitivity of the Duke-ISCVID criteria was 80%. None of the 475 episodes reclassified to possible IE were treated as IE. The Duke-ISCVID criteria reclassified a small proportion of episodes to definite IE at the expense of more episodes of possible IE. Future criteria should minimize the possible IE group while keeping or improving sensitivity.

Surgical Treatment of Active Endocarditis Pre- and Post-COVID-19 Pandemic Onset.

Despite advanced diagnosis and treatment, infective endocarditis (IE) is a potentially life-threatening condition. The impact of COVID-19 on the diagnosis and outcome of the surgical treatment of IE is uncertain. The aim of this study was to analyze the incidence, characteristics, and outcomes of surgically treated IE before and after the COVID-19 pandemic. This study retrospectively analyzed the data of 535 patients who underwent valve surgical procedures for IE between January 2010 and December 2022 in a single cardiac surgery center. Patients were divided into two groups depending on the date of their operation: before (n = 393) and after (n = 142) COVID-19 onset. In order to balance the groups, inverse probability of treatment weighting (IPTW) calculated from the propensity score (PS) was applied. Weighted univariate logistic regressions were reported for outcomes; weights were derived from IPTW. Interrupted time series analysis (ITSA) according to Linden's method was used to evaluate the changes in the manifestation of IE after 11 March 2020. Patients from the post-COVID-19 cohort (after 11 March 2020) had a greater number of comorbidities such as diabetes (29.6% vs. 16.3% p = 0.001), hypertension (71.1% vs. 59.5% p = 0.015), and preoperative kidney injury requiring dialysis (9.2% vs. 2.5% p = 0.002), but the median additive and logistic EuroSCORE were not statistically different. In the post-COVID-19 group, we observed a greater prevalence of Staphylococcus aureus-related endocarditis (24.5% vs. 15.4% p = 0.026), a consequent reduction in Staphylococcus non aureus-related endocarditis (12.2% vs. 20.1% p = 0.048), and a decrease in aortic valve replacements (43.0% vs. 53.9%), while the number of mitral valve replacements and repair was greater (21.1% vs. 15.0% and 6.3% vs. 4.3%, respectively). No differences were found in the two groups concerning early death, death, or relapse at 1 year after surgery. Data obtained by multivariable analysis identified preoperative renal dysfunction requiring dialysis as the only common risk factor for early mortality via stratifying by time periods in analysis. The incidence of surgically treated IE significantly increases after the COVID-19 pandemic with a higher incidence of mitral valve involvement with respect to the aortic valve. Although a delay in surgical timing occurred during the COVID-19 pandemic, data in terms of mortality and outcomes were largely unaffected.

New Antimicrobials and New Therapy Strategies for Endocarditis: Weapons That Should Be Defended.

The overall low-quality evidence concerning the clinical benefits of different antibiotic regimens for the treatment of infective endocarditis (IE), which has made it difficult to strongly support or reject any regimen of antibiotic therapy, has led to a discrepancy between the available guidelines and clinical practice. In this complex scenario, very recently published guidelines have attempted to fill this gap. Indeed, in recent years several antimicrobials have entered the market, including ceftobiprole, ceftaroline, and the long-acting lipoglycopeptides dalbavancin and oritavancin. Despite being approved for different indications, real-world data on their use for the treatment of IE, alone or in combination, has accumulated over time. Furthermore, an old antibiotic, fosfomycin, has gained renewed interest for the treatment of complicated infections such as IE. In this narrative review, we focused on new antimicrobials and therapeutic strategies that we believe may provide important contributions to the advancement of Gram-positive IE treatment, providing a summary of the current in vitro, in vivo, and clinical evidence supporting their use in clinical practice.

Partial oral versus full intravenous antibiotic treatment of endocarditis in people who inject drugs: A systematic review.

Prolonged intravenous (IV) antibiotic therapy may not be optimal for people who inject drugs (PWID) with infective endocarditis (IE) due to unique social and medical needs. The role of partial IV antibiotic therapy with continued oral (PO) antibiotic therapy is unclear. A systematic review was performed using EMBASE and MEDLINE databases. Included studies compared PO to IV antibiotic treatment for IE in PWID. Four studies met eligibility. Observational studies included full IV treatment groups and partial IV, partial PO treatment groups for severe injection-related infections. PWID with IE comprised 41.0%-64.7% of the study populations but outcomes specific to IE were not separately reported. All-cause 90-day readmission rates were comparable between the IV treatment group (27.9%-31.5%) and partial IV, partial PO treatment group (24.8%-32.5%). Ninety-day mortality was non-significantly different between IV treatment (4.9%-10.7%) and partial IV, partial PO treatment groups (2.4%-13.0%). One small randomized clinical trial compared IV oxacillin or vancomycin with gentamicin to PO ciprofloxacin plus rifampin. The cure rates were 91% and 90%, respectively. There is limited evidence comparing IV treatment to partial IV, partial PO antibiotic treatment in PWID with IE. Observational studies suggest that PO antibiotic therapy after initial IV treatment may be equivalent to full IV treatment alone within specific parameters, but randomized trials are needed to inform recommendations. Substantial clinical and social benefits for PWID and advantages for the health care system will result if PO treatment strategies with equal efficacy can be implemented.

Sex Differences in Infective Endocarditis: A Systematic Review.

Despite the advancement in medicine, there is still a lack of understanding of the sex disparities in disease onset, progression, treatment, and outcome. In some life-threatening acute conditions, despite most patients with these illnesses being males, females have a significantly higher chance of mortality. This can be due to the differences in disease progression or healthcare disparities in managing the illness between the sexes. Treatment of illnesses tends to be more conservative for women without an explanation, but this disparity is due to the healthcare provider. Infective endocarditis (IE) is an acute life-threatening condition where bacteria latch onto and seed damaged endocardium, with some preliminary information reporting differences between the sexes. This paper aims to evaluate the sex disparities in the incidence, age, comorbidities, etiology, risk factors, manifestations, treatment, and outcomes of IE. From 2003-2023, 21584 articles were found that focused on the sex differences in IE and, through PRISMA guidelines, were narrowed down to 34 publications. There are significant differences between the sexes in IE, such as a significantly higher incidence of IE in males, who also tend to be older and have their native aortic valves involved, compared to younger females who have their mitral valve involved. Comorbidities also vary between the sexes; females tend to have atrial fibrillation, chronic kidney disease, psychiatric disorders, and taking immunosuppressants compared to males who suffer from chronic liver disease, underlying valve disease, and peripheral artery disease, contributing to the ease of developing IE. While the most common microorganism leading to IE is Staphylococcus aureus, females were more likely to have culture-negative IE, and men were more likely to be infected with Streptococcus viridans. Major manifestations in IE are fever and vegetation along the closure of the valves in the heart, where females were more likely to have vegetation on the mitral and aortic valves. At the same time, males were more likely to have it on the tricuspid valve. On par with sex disparities in health, females usually took longer to seek medical help than males despite the advancement of symptoms and deterioration. Females were also treated conservatively through antibiotic management, whereas males were more likely to advance to surgical treatment, leading to a longer hospital stay. While there was no true difference in the in-hospital mortality rate, the 30-day and 1-year mortality were significantly increased in females. These differences provide a range of starting points for various research to further educate physicians on sex disparities, such as why males have a higher incidence of infective endocarditis and determining whether it's hormones and basic metabolites, possibly limiting those who develop the infection. Another important point is treating females with IE; the antibiotic doses are standard, but whether they advance to surgical treatment is mostly up to the provider. Some providers deny surgical treatment despite all indications, but it could also be females denying surgery as they tend to leave against medical advice. This review is crucial in developing the next steps to sex disparity in IE, which may lead to better outcomes for males and females.

Abstract 16036: Concomitant Culture-Negative Left-Sided Native Valve Endocarditis With Splenic Emboli and Babesiosis: A Case Report

Description of Case: A 76-year-old man with type 2 diabetes and a previously drained hepatic abscess presented with 3 days of fevers and chills associated with dizziness, weakness, and fatigue after hiking at a New York State Park. He denied any shortness of breath, chest pain, abdominal pain, diarrhea, skin rashes, insect bites, IV drug use, recent travel or sick contacts but reported having dental work one month prior to admission. Initial vital signs were notable for a fever of 38.4°C with a blood pressure of 145/76, heart rate of 90, and physical examination was unremarkable. Extensive laboratory studies were drawn, which initially were notable for normocytic anemia, thrombocytopenia, low haptoglobin and elevated lactate dehydrogenase. Empiric antibiotics were initiated as the patient met criteria for systemic inflammatory response syndrome (SIRS). CT abdomen and pelvis was remarkable for right-sided spleen with polysplenia and multiple peripheral wedge-shaped splenic infarcts. A transthoracic echocardiogram (TTE) was inconclusive for infective endocarditis (IE). A subsequent transesophageal echocardiogram (TEE) showed vegetations on the aortic and mitral valves with mild regurgitation respectively. After cardiothoracic surgery evaluation, he was deemed not a surgical candidate. Blood and urine cultures remained negative, but the Babesia antibodies IgM and IgG antibodies, and Babesia microti PCR was detected. He was started on atovaquone 750 mg twice daily and azithromycin 250 mg once daily for 10 days for babesiosis. He was discharged on vancomycin 1g every 12 hours and ceftriaxone 2g every 24 hours for a total of 6 weeks for empiric IE treatment given splenic emboli. Discussion : We describe a rare case of fever caused by culture-negative mitral and aortic valvular endocarditis with splenic emboli and babesiosis. Recent dental work and hiking outdoors in the Northeast United States of America were the key predisposing factors. Given splenic infarcts, pursuing a TEE was pivotal in ascertaining the diagnosis. The patient received empiric IE treatment for gram-positive cocci, HACEK organisms and babesiosis with improvement of symptoms. Identifying and treating unusual causes of fever and SIRS are crucial in reducing mortality and morbidity.

Abstract 17647: Potential Candidates for Partial Oral Treatment in Patients With Endocarditis at a US Center

Introduction: In the Danish POET trial, oral step-down antibiotic therapy was non-inferior to intravenous antibiotic therapy (IVAB) in stabilized patients with left-sided infective endocarditis (IE). It is unknown whether oral treatment for IE can be efficacious in the US population. Aim Identify patients with IE who may have been candidates for POET treatment in a US cohort and assess the reduction of IVAB days and differences in characteristics and outcomes compared to participants in the POET trial. Methods: Retrospective study of patients admitted with IE at a US single center in Jan 2021 - July 2022. Possible candidates for POET treatment were patients with left-sided IE and infection with S. aureus , E. faecalis , Streptococcus , or coagulase-negative staph (CoNS), who had reached stabilization of infection or were discharged. Primary outcome was a composite of all-cause mortality, relapse of bacteremia, embolism or unplanned cardiac surgery within 6 months. Results: Of 152 patients with IE, 90 (59%) were possible candidates for POET treatment. Median length of IVAB after stabilization was 33 days (IQR 24-37). Compared to POET-trial patients, POET candidates in the US cohort were younger (64 vs 70 years), more often had diabetes (30% vs 17%), cancer (30% vs 8%), intravenous substance use (8% vs 1%) or pacemakers (18% vs 9%) [Table]. Prevalence of S. aureus (35% vs 22%) and CoNS infections (23% and 6%) was higher; Streptococcus was less common (30% vs 49%). Primary outcome occurred in 25 patients (28%) compared to 42 patients (10%) in the POET-trial (p<0.001). Conclusions: More than half of patients admitted with IE were possible POET candidates, for whom 4 weeks of IVAB may have been converted to oral antibiotics. Candidates in the US cohort had more comorbidities and primary outcome was three times higher than in the POET trial. Prospective studies are needed for verification of POET treatment in higher-risk US IE patients.

Comparison of dalbavancin with standard of care in the management of infective endocarditis: efficacy, safety, and cost analysis

ObjectivesDue to its long half-life, dalbavancin offers benefits for long-duration treatments, especially osteoarticular and infective endocarditis (IE). We evaluated the efficacy and costs of IE treatment, comparing dalbavancin with standard of care (SOC). MethodsRetrospective multicenter cohort study of adult patients with Gram-positive cocci definite IE. Dalbavancin was used as a sequential therapy before discharge. Efficacy was a combined variable of clinical cure and absence of recurrence in 12-month follow-up. Length of hospital stay and the associated costs were analyzed in both groups of treatment. ResultsTwenty-two patients received dalbavancin and 47 SOC. The efficacy was similar between the groups (dalbavancin 18 [72%] vs SOC 44 [94%], P = 0.198). Hospital stay was shorter in the dalbavancin group (dalbavancin 22 days [16-34] vs SOC 37 days [23-49], P = 0.001), especially in those with E. faecalis IE (dalbavancin 30 days [20-36] vs SOC 65 days [46-74], P <0.001). A reduction of cost was observed between both groups (dalbavancin, 12,206 € [8998-17,283] vs SOC 16,249 € [11,496-22,367], P = 0.032). ConclusionDalbavancin could be a safe and effective option in the sequential treatment of patients with IE. Also, a cost reduction was detected, due to a significant shortness of hospital stay.

Contemporary use of cefazolin for MSSA infective endocarditis: analysis of a national prospective cohort

ObjectivesThis study aimed to assess the real use of cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis (IE) in the Spanish National Endocarditis Database (GAMES) and to compare it with antistaphylococcal penicillin (ASP). MethodsProspective cohort study with retrospective analysis of a cohort of MSSA IE treated with cloxacillin and/or cefazolin. Outcomes assessed were relapse; intra-hospital, overall, and endocarditis-related mortality; and adverse events. Risk of renal toxicity with each treatment was evaluated separately. ResultsWe included 631 IE episodes caused by MSSA treated with cloxacillin and/or cefazolin. Antibiotic treatment was cloxacillin, cefazolin, or both in 537 (85%), 57 (9%), and 37 (6%) episodes, respectively. Patients treated with cefazolin had significantly higher rates of comorbidities (median Charlson Index 7, P <0.01) and previous renal failure (57.9%, P <0.01). Patients treated with cloxacillin presented higher rates of septic shock (25%, P = 0.033) and new-onset or worsening renal failure (47.3%, P = 0.024) with significantly higher rates of in-hospital mortality (38.5%, P = 0.017). One-year IE-related mortality and rate of relapses were similar between treatment groups. None of the treatments were identified as risk or protective factors. ConclusionOur results suggest that cefazolin is a valuable option for the treatment of MSSA IE, without differences in 1-year mortality or relapses compared with cloxacillin, and might be considered equally effective.

Risk of Infective Endocarditis Post-transcatheter Pulmonary Valve Replacement Versus Surgical Pulmonary Valve Replacement: A Systematic Review.

Pulmonary valve replacement (PVR) is the most common cardiac operation in adult patients with congenital heart disease (ACHD). It can improve right ventricular outflow tract (RVOT) obstruction, typically due to pulmonary valve stenosis or regurgitation. PVR can be performed surgically (open-heart) and through a transcatheter (percutaneous) method, which is minimally invasive and is associated with shorter hospitalization stays. However, following PVR, infectious endocarditis (IE) can complicate the recovery process and increase mortality in the long term. IEis a rare but deadly multi-organ system condition caused by microorganisms traversing the bloodstream from a specific entry point. It can have many presentations, such as splinter hemorrhages, fevers, and vegetation on valves that lead to stroke consequences. This paper aims to evaluate the differences in the rate, etiology, manifestations, treatment, and outcomes of IE following surgical and transcatheter PVR, as the goal is to perform a procedure with few complications. In both approaches, Staphylococcusaureus was the most common microorganism that affected the valves, followed by Streptococcus viridians. Research has shown that surgical pulmonary valve replacement (SPVR) has a decreased risk of IE following surgery compared to TPVR. However, TPVR is preferred due to the reduced overall risk and complications of the procedure. Despite this, the consensus on mortality rates does differ. Future research should consider the type of valves used for transcatheter pulmonary valve replacement (TPVR), such as Melody valves versus Edward Sapien valves, as their IE rates vary significantly.

Postoperative complications and predictors of mortality in surgery for left-sided infective endocarditis: a single-center retrospective study

Aim. To assess postoperative complications and predictors of mortality in surgery for left-sided infective endocarditis (IE).Material and methods. The retrospective analysis included 222 cases of IE in 216 patients who were operated on from January 2015 to November 2022. Inclusion criteria: age of patients ≥18 years, definite or probable (Duke criteria) left-sided IE of aortic and/or mitral valves. There were following exclusion criteria: isolated right-sided IE (tricuspid valve, pacemaker endocarditis), nonbacterial thrombotic endocarditis and chronic IE. Endpoints: inhospital mortality, postoperative complications (delirium; perioperative stroke; resternotomy for bleeding; perioperative myocardial infarction; acute heart failure requiring extracorporeal membrane oxygenation or intra-aortic balloon pumping; respiratory failure requiring tracheostomy; acute kidney injury requiring renal replacement therapy; conduction disorder requiring pacemaker implantation).Results. Median age was 53 [38,0; 61,0] years, while the majority of patients were men (73,9%). Inhospital mortality was 8,6%. The most common postoperative complications were delirium (19,8%) and bleeding requiring resternotomy (10,4%). The incidence of perioperative stroke was 2,3%, perioperative myocardial infarction - 0,9%, respiratory failure with tracheostomy – 4,5%, pacemaker implantation – 2,7%, renal replacement therapy – 6,8%. According to multivari ate analysis, Predictors of inhospital mortality were creatinine clearance level (odds ratio (OR), 0,976; 95% confidence interval (CI): 0,956-0,996; p=0,020), time of cardiopulmonary bypass (OR, 1,014; 95% CI: 1,006-1,021 , p&lt;0,001), deli rium (OR, 7,058; 95% CI: 1,824-27,330, p=0,005) and acute kidney injury requiring renal replacement therapy (OR, 28,620; 95% CI: 6,508-125,964; p&lt;0,001).Conclusion. Surgical treatment of left-sided IE has satisfactory inho spital outcomes. The study identified simple clinical factors (creatinine clearance, cardiopulmonary bypass time, delirium, acute kidney injury) associated with inhospital mortality.

Anévrysme rénal infectieux retardé, 3 mois après chirurgie cardiaque pour une endocardite infectieuse à Streptococcus pyogenes ; cas et revue de la littérature

Infective endocarditis (IE) due to Streptococcus pyogenes (SP) (Group A Streptococcus) is uncommon and infectious renal artery aneurysm (IRAA) is an exceptional complication of IE, with few cases reported in the literature.We describe a case of SP native mitral valve IE in a 58-year-old man, presenting with large valve vegetations, abscess and severe regurgitation. Initial CT-angiography showed bilateral kidney and splenic infarcts.He underwent successful emergent bioprosthetic valve replacement. Antibiotic regimen consisted in linezolid and rifampicin for 8 weeks. Three months later, CT-angiography for feet gangrene revealed a 16mm aneurysm of the left intraparenchymal renal artery, which was occluded by coil-embolization.This case shows that an infectious aneurysm may develop several months after antibiotic treatment and emergent valve replacement for IE.

EN-DALBACEN 2.0 Cohort: real-life study of dalbavancin as sequential/consolidation therapy in patients with infective endocarditis due to Gram-positive cocci

Infective endocarditis (IE) has high mortality and morbidity and requires long hospital stays to deliver the antibiotic treatment recommended in clinical practice guidelines. We aimed to analyse the health outcomes of the use of dalbavancin (DBV) in the consolidation treatment of IEs caused by Gram-positive cocci and to perform a pharmacoeconomic study. This observational, retrospective, Spanish multicentre study in patients with IE who received DBV as part of antibiotic treatment in consolidation phase were followed for at least 12 months. The study was approved by the Provincial Committee of the coordinating centre. The study included 124 subjects, 70.2% male, with a mean age of 67.4 years and median Charlson index of 4 (interquartile range: 2.5-6). Criteria for definite IE were met by 91.1%. Coagulase-negative staphylococci (38.8%), Staphylococcus aureus (22.6%), Enterococcus faecalis (19.4%), and Streptococcus Spp. (9.7%) were isolated more frequently, all susceptible to vancomycin. Before DVB administration, 91.2% had undergone surgery; 60.5% had received a second regimen for 24.5 d (16.6-56); and 20.2% had received a third regimen for 14.5 d (12-19.5). DBV was administered to facilitate discharge in 95.2% of cases. At 12 months, the effectiveness was of 95.9%, and there was 0.8% loss to follow-up, 0.8% IE-related death, and 3.2% relapse. Adverse events were recorded in 3.2%. The hospital stay was reduced by 14 d, and there was a mean savings of 5548.57 €/patient vs. conventional treatments. DBV is highly effective, safe, and cost-effective as consolidation therapy in patients with IE by Gram-positive cocci, with few adverse events.

Mitral homograft in tricuspid position: indications for implantation and surgical technique

HighlightsThe article presents the latest data on the techniques of implantation of the mitral homograft in the tricuspid position, and identifies groups of patients who are best suited for this method. Moreover, the article describes the evolution of this type of replacement, and highlights that many surgical techniques, although justified, require further study to show demonstrate their advantages. AbstractDespite the general trend in cardiac surgery towards valve-preserving interventions, valve replacements remain relevant, and the search for the perfect prosthetic valve continues. Many believe that tricuspid valve replacement using a mitral homograft can be the method of choice in certain situations. The analysis of the studies found in the PubMed database led the authors to the following conclusions: most of the data on the use of this technique in patients with infective endocarditis (IE), other indications are congenital heart disease (CHD) and rheumatic heart disease. Patients with IE who have undergone tricuspid valve replacement using a mitral homograft have good medium-term prospects, and respond well to medical treatment of recurrent IE. The mitral homograft in the tricuspid position remains intact even after prosthetic endocarditis. In this regard, it is possible to perform reconstructive intervention in case of prosthetic valve dysfunction without the need for repeated replacement. Such interventions are relevant for patients with growing heart for whom annuloplasty at the first stage of surgery is undesirable. Moreover, it is also cost-effective due to the high cost and low availability of homografts. The possibility of repeated tricuspid valve-in-valve replacement is important for patients who may not survive open surgery. To date, there are not enough long-term and short-term data on using a mitral homograft for tricuspid valve replacement, however, it can be assumed that the results of this technique will be positive provided that the appropriate implantation technique and strict patient selection are ensured. Many authors have come to the conclusion that the optimal homograft implantation technique includes sewing of the graft`s papillary muscles into the wall of the myocardium of the right ventricle (RV), fixating them on the outer surface of the RV, anatomical positioning of the homograft (anterior leaflet faces towards the IVS), and the use of an annuloplasty ring.

Differential response to antibiotic therapy in staphylococcal infective endocarditis: contribution of an ex vivo model.

Staphylococcal infective endocarditis (IE) remains a hard-to-treat infection with high mortality. Both the evaluation of new innovative therapies and research on alternative models mimicking human IE are therefore urgently needed to improve the prognosis of patients with diagnosed IE. Dalbavancin is a novel anti-staphylococcal lipoglycopeptide but there are limited data supporting its efficacy on biofilm infections. This antibiotic could be an alternative to current therapies for the medical treatment of IE but it needs to be further evaluated. Here we developed an original ex vivo model of Staphylococcus aureus IE on human heart valves and assessed biofilm formation on them. After validating the model, the efficacy of two antistaphylococcal antibiotics, vancomycin and dalbavancin, was compared by measuring and visualizing their respective ability to inhibit and eradicate late-formed biofilm. Determination of the minimum biofilm inhibitory (MbIC) and eradicating (MbEC) concentrations in our ex vivo model identified dalbavancin as a promising drug with much lower MbIC and MBEC than vancomycin (respectively <0.01 versus 28 mg/L and 0.03 versus 32 mg/L). These data highlight a strong bactericidal effect of dalbavancin, particularly on an infected heart valve compared with vancomycin. Dalbavancin could be a realistic alternative treatment for the management of staphylococcal IE.

Heartbreaking Decisions: The Dogma and Uncertainties of Antimicrobial Therapy in Infective Endocarditis.

Infective endocarditis (IE) is a rare but increasingly prevalent disease with high morbidity and mortality, requiring antimicrobials and at times surgical intervention. Through the decades of healthcare professionals' experience with managing IE, certain dogmas and uncertainties have arisen around its pharmacotherapy. The introduction of new antimicrobials and novel combinations are exciting developments but also further complicate IE treatment choices. In this review, we provide and evaluate the relevant evidence focused around contemporary debates in IE treatment pharmacotherapy, including beta-lactam choice in MSSA IE, combination therapies (aminoglycosides, ceftaroline), the use of oral antimicrobials, the role of rifamycins, and long-acting lipoglycopeptides.

Amoxicillin therapeutic drug monitoring for endocarditis: A comparative study (EI-STAB)

IntroductionInternational guidelines recommend high doses of β-lactams for most cases of infective endocarditis (IE). Therapeutic drug monitoring (TDM) is increasingly used to adjust β-lactam dose based on plasma concentrations, although there are no comparative studies to support this practice. The benefit of amoxicillin TDM during IE was evaluated. MethodsAn observational, retrospective, cohort study of adults treated with high-dose amoxicillin for enterococcal or streptococcal IE was conducted in two referral centers. Patients with, or without TDM were compared. The primary outcome was mean daily amoxicillin dose. ResultsA total of 206 cases of streptococcal (n=140, 68%) or enterococcal (n=66, 32%) IE were included. IE occurred on prosthetic valves in 77 (37%) cases, and on intracardiac devices in 28 (14%) cases. Aortic valve was involved in 136 (66%) cases. There were 154 men (75%), mean age was 70 ± 14 years, valve surgery was performed in 81/206 (39%) patients, and in-hospital mortality was 8% (17/206). All patients in the TDM group and most patients in the group without TDM received amoxicillin as continuous infusion. Amoxicillin TDM was performed for 114 patients (55.3%), with a mean of 4.7 ± 2.3 measures per patient, a mean plasma steady-state concentration of 41.2 ± 19 mg/L, most (82/114, 72%) being within the therapeutic target (20–80 mg/L). Mean amoxicillin dose was lower in patients with TDM (10.0 ± 3.3 g/day) than those without TDM (11.3 ± 2.0 g/day) (P=0.003). ConclusionAmoxicillin TDM was associated with a reduction in daily doses, with no impact on adverse events and prognosis. Individualized treatment of IE through TDM may contribute to decreased use of antibiotics.