Treatment Of Infective Endocarditis Research Articles

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

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

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

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

Oral antibiotics for infective endocarditis: a clinical review.

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

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

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

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

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

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

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

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

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

Infective endocarditis - can we treat it more effectively?

Infective endocarditis (IE), despite the diagnostic and therapeutic advances, still remains a serious disease associated with high mortality and serious complications. The present guidelines of the European Cardiology Society of 2015 recommend administration of the antibiotics indicated in empirical therapy for multiple weeks and in targeted treatment often for 6–8 weeks. This is associated with a risk of adverse effects of antibiotic therapy in the form of nephro- and/or hepatotoxicity and an increased risk of infections with Clostridioides difficile, while long-term hospitalisation is associated with high non-drug costs. The recommendations developed by the Austrian Society for Infectious Diseases and Tropical Medicine list dalbavancin among the new antibiotics that may find application in the treatment of IE of staphylococcal aetiology. This antibiotic is a lipoglycopeptide antibiotic alternative to vancomycin in the treatment of Staphylococcus aureus MRSA infections, especially in a situation where the minimum inhibitory concentration for vancomycin is high but below the breakpoint. Dalbavancin has very good pharmacokinetic and pharmacodynamic properties, with a long duration of action of up to 14 days after administration of a single dose (1500 mg in a 30-minute infusion). This antibiotic is characterised by high clinical efficacy with good treatment tolerance and safety profile, without causing toxic effects in internal organs in comparison with vancomycin. In view of its safety, clinical efficacy and convenient dosing, dalbavancin may prove a useful therapeutic option in the treatment of IE.

Early and intermediate outcomes for surgical management of infective endocarditis

ObjectiveThe treatment of active infective endocarditis (IE) presents a clinical dilemma with uncertain outcomes. This study sets out to determine the early and intermediate outcomes of patients treated surgically for active IE at an academic medical center.MethodsA retrospective chart review was conducted to identify patients who underwent surgical intervention for IE at our institution from July 1st, 2011 to June 30th, 2018. In-patient records were examined to determine etiology of disease, surgical intervention type, postoperative complications, length of stay (LOS), 30-day in-hospital mortality, and 1-year survival.ResultsTwenty-five patients underwent surgical intervention for active IE. The average age of the patients was 47 ± 14 years old and most of the patients were male (N = 15). The majority of the patients had the mitral valve replaced (N = 10), with the remaining patients having tricuspid (N = 8) and aortic (N = 7) valve replacements. The etiology varied and included intravenous drug use (IVDU), and presence of transvenous catheters. The 30-day in-hospital mortality was 4% with 1 patient death and the 1-year survival was 80%. The average LOS was 27 days ±15 and the longest LOS was 65 days.ConclusionsSurgical management of IE can be difficult and challenging however mortality can be minimized with acceptable morbidity. The most common complication was CVA. The average LOS is longer than traditional adult cardiac surgery procedures and the recurrence rate of valvular infection is not minimal especially if the underlying etiology is IVDU.

Patient Characteristics Affect Discharge Status for Opioid-related Infective Endocarditis.

Opioid overdoses have increased dramatically in the last 20 years, but secondary complications, such as infective endocarditis (IE) are also on the rise. The objective of this study was to understand the effect that opioid-related IE has on hospitals across the US and to understand the disposition of patients after treatment for IE, particularly in regard to insurance status and type. Secondary data analysis of the publicly-available 2015 Nationwide Inpatient Sample (NIS) was used to assess opioid-related IE based on patient and hospital characteristics. Bivariate and logistic regression was calculated to determine significance between the outcome variable (IE) and other covariates. The 2015 NIS data contained 7,153,989 weighted observations with 5760 (0.02%) incidences of opioid-related IE. The NIS dataset represents a 20% stratified sample of all US hospitalizations across all payors in a given year. Opioid-related IE was the outcome variable measured through ICD-9 and ICD-10 codes, and the independent variables included the patient's age, sex, primary payer, household income, discharge status, length of stay, and transfer status, and the hospital's size, ownership, region, and location with teaching status. Routine discharge was the top discharge status across all payors, except Medicare. Nearly 26% of self-pay patients were discharged against medical advice. Logistic regression results indicate that patients who are younger, uninsured, have increased condition severity, have longer lengths of stay, and are discharged against medical advice or transferred to a short-term hospital or other health facility experienced significantly higher odds of opioid-related IE admissions as compared with all other admissions. The only significant hospital characteristic was region. The fact that patient disposition varied across different payors suggests that hospitals are missing opportunities to engage the most vulnerable patients with IE. Given the long-term care required by this condition, hospitals are well-positioned to participate in interventions to initiate substance abuse treatment and help patients navigate outpatient substance abuse treatment options.

126. Cascade of Care for Opioid Use Disorder in Patients with Infective Endocarditis

BackgroundThe term “Cascade of Care” has been used to analyze care delivered by a health system for conditions such as HIV, hepatitis C, tuberculosis, and diabetes. It outlines sequential steps required to reach a specific outcome (i.e., viral suppression in the case of HIV). This allows to estimate the proportion of patients achieving each step and to identify gaps in care. Medication-assisted treatment (MAT) is integral in the treatment of patients with infective endocarditis (IE) and opioid use disorder (OUD). We propose a Cascade of Care aiming to identify fundamental milestones in the management of these patients.MethodsA retrospective cohort study examined patients with IE in the setting of OUD hospitalized between July 1, 2007 and January 1, 2015 to the Cleveland Clinic. We identified 4 key steps along the treatment cascade of these patients and estimated the proportion of patients: (1) evaluated by an addiction treatment service, (2) prescribed MAT while in-patient, (3) prescribed MAT at discharge, and (4) continued MAT at least 90 days after discharge.ResultsOf 273 patients with IE in the setting of OUD, 134 (49%) were evaluated by an addiction treatment service; 45 (17%) were prescribed MAT while in-patient; only 22 (8%) were prescribed MAT at discharge. At 90 days following discharge, there was evidence of continuing MAT for all 22 patients (8%).ConclusionDescribing the process of addiction treatment for patients with IE and OUD in the format of a cascade of care provides a powerful quantitative method to identify gaps in care and can be used as a resource to implement interventions to address losses. We found only 8% of these patients continued MAT in the community after discharge. This study provides an estimate of how compromised the potential benefits from medical and surgical treatment for IE are by the lack of an effective approach to OUD after hospital discharge. Disclosures All authors: No reported disclosures.

193. Comparison of Survival for MSSA and MRSA Endocarditis

BackgroundPrior studies have yielded conflicting findings regarding outcomes for MRSA vs. MSSA infective endocarditis (IE). Our experience suggests that MSSA IE is not any less severe than MRSA IE. The purpose of this study was to compare survival in MSSA and MRSA IE.MethodsEpisodes of IE caused by Staphylococcus aureus were identified from the Cleveland Clinic Infective Endocarditis Registry. Only the first episode was included for each patient. Acceptance for surgery was considered surgical treatment. Survival from the surgical decision date was compared for MSSA vs. MRSA endocarditis using multivariable Cox proportional hazards regression. Selection of variables for the model was done by stepwise backward elimination from a collection of clinically important baseline variables.ResultsBetween January 1, 2008 and January 1, 2010, 76 episodes of IE caused by S. aureus were identified. The mean (SD) patient age was 58 (15) years, 46 (61%) were males, 14 (18%) had a prior history of IE, 33 (43%) had diabetes mellitus, 22 (29%) had end-stage renal disease (ESRD), 27 (36%) had prosthetic valve endocarditis (PVE), 70 (92%) had left side involvement, 27 (36%) had invasive disease, 59 (78%) were referred patients, and 39 (51%) were treated surgically. The mean (SD) time to decision on surgery was 6 (7) days. Of these episodes 40 (53%) had MSSA IE and 36 (47%) had MRSA IE. There was no difference in hazard of death between MSSA and MRSA IE (HR 0.98, 95% C.I. 0.54–1.78, P-value 0.96), after adjusting for age, ESRD, prior history of IE, PVE, invasive disease, calendar year, and surgical treatment, which were the significant explanatory variables in the multivariable analysis. Survivals predicted by the model for a reference patient with MSSA IE and MRSA IE are shown in the figure.ConclusionPreliminary findings suggest that survival in MSSA IE may be similar to that in MRSA IE. The study is limited by its small sample size. The study finding will need confirmation with a larger sample. Disclosures All authors: No reported disclosures.

The infective endocarditis of synthetic patch after left ventricle reconstruction (Dor procedure)

Infective endocarditis (IE) has become an increasingly significant problem in cardiology and cardiac surgery over the past 30 years. Despite the noticeable progress made in the diagnosis and treatment of IE, the prognosis for this condition is still poor and the mortality rate reaches 15-30% [1, 2]. The risk of developing IE is especially high in patients with «intracardiac» artificial materials (artificial valves, prostheses of any type, implantable antiarrhythmic devices). This article presents a rare clinical case of IE of synthetic patch after left ventricle reconstruction (Dor procedure).

Current Evidence on Oral Antibiotics for Infective Endocarditis: A Narrative Review.

Infective endocarditis (IE) continues to be associated with high morbidity and mortality, even when treated with optimal antibiotic regimens. The selection of treatment depends on the causative pathogen, its antibiotic susceptibility profile, local and systemic complications and the presence of prosthetic materials or devices. Standard therapy typically involves 4–6 weeks of intravenous (IV) bactericidal therapy. However, there are instances in which IV antibiotic administration may be challenging due to cost, complications of IV access, adverse side-effects of the medication or concerns for misuse of the IV line. Current clinical guidance from the American Heart Association and the European Society of Cardiology cite scenarios where oral antibiotics can be considered for treatment of IE, though these situations are relatively infrequent and data to show their non-inferiority limited. Recently, a well-designed randomized clinical study reported favorable outcomes for partial oral antimicrobial therapy regimens given to patients with staphylococcal, streptococcal and enterococcal IE deemed clinically stable and without complications such as perivalvular abscess. Oral antibiotics, usually given in combination, were selected by infectious disease providers for their favorable pharmacologic properties and predicted bactericidal activity. There was a careful selection of patients who were transitioned to oral regimens. Before recommending routine use of oral antibiotics in the care of patients with IE, additional studies that better define eligible patients and that use regimens available in the countries that adopt this practice should be performed. If further studies confirm non-inferior outcomes with partial oral antibiotics for the treatment of IE, medical treatment could be delivered in a simpler, more costeffective manner, and likely with lower rates of adverse side-effects.

Antimicrobial Treatment of Infective Endocarditis, Caused by <i>Enterococcus Faecalis

The frequency of infective endocarditis (IE) has increased 3 times over the past 30 years. The incidence of IE morbidity is recorded in all countries of the world and in the Russian Federation more than 40 people per 1 million population get sick. One of the most frequent causative agents of infective endocarditis is Enterococcus faecalis (E. faecalis), which takes the third place in the structure of the frequency of IE pathogens. Enterococcal IE remains a disease with high mortality, despite the emergence of new groups of antibacterial drugs. This review includes the results of studies of the efficacy and safety of various antimicrobial regimens of IE caused by E. faecalis. The analysis of data from foreign and native studies of antimicrobial treatment in patients with infective endocarditis, accompanied by enterococcal bacteremia is presented in the review. The search for literature performed by using medical databases: MEDLINE, EMBASE, eLIBRARY. The current review included studies of the efficacy and safety of antimicrobial treatment. The main antibiotic therapy regimens of IE caused by E. faecalis include 2 beta-lactam antibiotics or a combination of ampicillin and gentamicin, according to the results of 5 found studies. Found antimicrobial regimens significantly did not affect mortality. Data from international registries testify to the efficacy and safety of daptomycin monotherapy for enterococcal endocarditis. Linezolid and daptomycin are the main drugs of treating infective endocarditis caused by vancomycin-resistant enterococci. Native studies report of a high level of resistance of enterococcal strains to beta-lactam antibacterial drugs. The duration of fever, the frequency of surgical heart valves interventions, the duration of bacteremia are not fully represented in each of the studies, and it is difficult to evaluate these factors. Ampicillin+ceftriaxone and ampicillin+gentamicin are the main antimicrobial treatment regimens of enterococcal endocarditis. Efficacy of these regimens is not significantly different. Treatment of IE should be carried out taking into the epidemiological situation and the strain resistance.

Diagnosis of infective endocarditis using echocardiography.

The aim of this study was to evaluate the application of transthoracic echocardiography for the diagnosis of infective endocarditis (IE) to provide a basis for the better treatment of IE. From October 2016 to October 2018, 87 consecutive patients with IE at our hospital were selected for this study. All the patients were subjected to transthoracic echocardiography. The morphology, structure, activity, and closure of the patients’ heart valves were observed for vegetation identification, and the size, number, location, morphology, and echo intensity of vegetation, as well as degree of valve involvement, were determined.The 87 patients investigated in this study included 38 cases of congenital heart disease, 27 cases of nonrheumatic valvular heart disease, 12 patients who underwent valve surgery, 5 cases of rheumatic valvular heart disease, and 5 patients with no obvious signs of heart disease. The most common clinical manifestations were heart murmur in 80 cases and fever in 60 cases. The most common complications were heart failure in 35 cases, followed by organ embolism in 12 cases. There were 36 cases of positive blood cultures, including 26 cases of Gram-positive cocci and 10 cases of Gram-negative bacilli. Echocardiography showed aortic valve involvement in 37 cases, mitral valve involvement in 34 cases, tricuspid valve involvement in 10 cases, pulmonary valve involvement in 2 cases, and the involvement of an artificial valve in 5 cases. Twenty-six of these cases showed multiple valve involvement, and 20 patients exhibited serious complications. No significant differences were found between echocardiography and actual surgical observations with respect to their accuracy in detecting the size, number, and location of vegetation in the 69 patients who underwent surgery (P > .05). Echocardiography could detect the occurrence of severe complications, namely, the rupture of chordae tendineae, valve prolapse, valve perforation, and paravalvular abscess, and no significant difference in diagnostic accuracy was found between echocardiography and surgical observations (P > .05).Transthoracic echocardiography can rapidly and accurately detect IE vegetation and its complications and has important clinical value for guiding clinical treatment and determining prognosis.

Current treatment of endocarditis : Innovations and controversies

Despite many novel diagnostic strategies and advances in treatment, infective endocarditis (IE) remains asevere disease. The epidemiology of IE has shifted and staphylococci have replaced streptococci as the most common cause and nosocomially acquired infections, invasive procedures, indwelling cardiac devices and acquired infections due to intravenous drug abuse are more frequent. The incidence of IE has steadily increased in recent years and the patients affected are older and have more comorbidities. The modern treatment of IE is interdisciplinary. The pharmacotherapy of IE depends on the pathogen and its sensitivity. The presence of abioprosthetic valve and implantable cardiac devices plays asignificant role in selection of antibiotics and duration of treatment. This article provides an update and overview of the current clinical practice in diagnostics and pharmacotherapy of IE in adults with aspecial focus on partial oral therapy and the role of aminoglycosides.

Evaluation of Perioperative Data in Patients with Infective Endocarditis Due to Antibiotic-Resistant Strains, Operated with the Use of Hyperthermic Perfusion

Objectives. Due to reduction of terms of in-hospital treatment and increased range of community-acquired medical interventions risk of infective endocarditis (IE) due to antibiotic-resistant microorganisms increases. Surgical treatment of IE due to antibiotic resistant strains requires complex approach including the terms of surgical intervention, rational etiotropic antibiotic therapy, adequate materials for intracardiac reconstructions, hyperthermic per-fusion during bypass and careful perioperative management.
 The objective of the study was to describe the influence of antibiotic resistance on clinical course and results of surgical treatment in patients with infective endocarditis, operated with the use of hyperthermic perfusion.
 Materials and methods. Clinical data of 227 consequent patients with active infective endocarditis, operated from 01/01/2016 to 01/11/2018 were analyzed. The mean age was 48.7 ± 15.5 years. Gram-positive microorganisms were identified in 210 (92.5%) cases. Among them vancomycin-resistant strains composed – 46 (22.1%)cases. Gram-negative cultures were found in 17 (7.5%) cases. In this group the rate of carbapenem-resistant strains reached 47.1% (8 cases). Patients were operated with the use of total controlled hyperthermic perfusion (TCHP). Comparative analysis of perioperative data was carried out.
 Results. The group of patients with IE due to antibiotic-resistant strains (N = 54) was characterized by a higher frequency of redo interventions for replacement of infected valves – 7 (12.9%) cases, intracardiac abscesses – 13 (24.1%) cases, and lower frequency of valve-repair procedures – 5 (9.2%) cases, indicating a significant degree of initial degradation of the valve (p < 0.05). Despite the absence of influence of the duration of aortic cross-clamping time, the total bypass time in the antibiotic-resistant group was significantly higher (p = 0.021). Analysis of hemodynamic status of patients revealed that the dose and duration of sympatho-mimetic administration were significantly higher in the group of patients with resistant microorganisms: dobutamine – 3.7 ± 0.6 ?g/kg/min and 113.2 ± 2.1 hours; norepinephrine – 0.09 ± 0.01 ?g/kg/min and 12.3 ± 2.1 hours respectively (p < 0.001). Surgical interventions in patients with IE due to antibiotic-resistant strains, had higher frequency of postoperative heart failure – 30.8% cases (p = 0.002) and hospital mortality – 5,8% (p = 0.017) cases.
 Conclusions. Application of TCHP allowed to decrease hospital mortality to 5.8% in surgical treatment of patients with IE, caused by antibiotic-resistant strains of microorganisms.

Results of Surgical Treatment of Infective Endocarditis Complicated with Lung Impairment

The initial lung impairment in patients with infective endocarditis (IE) has a negative impact on the results of surgical treatment and rate of postoperative respiratory failure (RF). Mechanisms of development of RF are quite complicated, but the leading role is played by the initial septic lesion of pulmonary tissue in IE and surgical treatment with the use of cardio-pulmonary bypass.
 The aim of the study was to analyze results of surgical treatment of patients with IE, operated with the use of cardio-pulmonary bypass, implementing the method of intraoperative lung protection.
 Materials and methods. The basis of the study was clinical data of 663 patients with IE who were examined and treated at the SE “Amosov National Institute of Cardiovascular Surgery of NAMS of Ukraine” from 01.01.2016 to 01.01.2018. Diagnosis of IE was established according to the Duke University criteria Anesthetic support was carried out in accordance with standard techniques. For intraoperative lung protection, together with perfusion of the pulmonary artery with arterial blood, the mechanical ventilation was maintained for the period of bypass circulation. For determination of pathomorphological changes of lungs in patients with IE, histological analysis of intraoperative lung biopsy was performed.
 Results. In the surgical treatment of patients with IE with the use of standard method of anesthesia support, the rate of RF in the early postoperative period was 52 (7.8%) cases. The use of the modified method of intraoperative management led to the decrease of the signs of adults respiratory distress syndrome during the postperfusion period: decrease in the edema liquid in the alveolar lumen (p = 0.027), decrease in protein precipitate in the alveolar lumen (p = 0.031), decrease in the incidence of signs of alveoli collapse (p = 0.002). The use of the lung protection method offset the negative impact of intraoperative volume of blood transfusion on the lung function after surgery and the duration of mechanical ventilation (r = 0.121, p = 0.522). The introduction of lung protective in patients with IE, operated with the use of cardio-pulmonary bypass, contributed to decrease in the rate of RF in the early postoperative period from 7.9% to 2.8% of cases in the study groups.
 Conclusions. Implementation of the new protocol allowed to conduct long-term surgical interventions with the use of cardio-pulmonary bypass without increasing duration of mechanical ventilation and reducing the oxygenation index in the postoperative period, and contributed to the decrease in the frequency of postoperative RF.

Daptomycin-containing regimens for treatment of Gram-positive endocarditis

Infective endocarditis (IE) is a severe infection, and a leading cause of mortality and morbidity. Due to its favourable microbiological and pharmacological characteristics, daptomycin is routinely used in clinical practice for treating IE. A prospective study was conducted at a large tertiary-care hospital in Italy over an 8-year period (January 2010-January 2018) on all patients with native-valve endocarditis (NVE) or prosthetic-valve endocarditis (PVE) caused by Gram-positive bacteria. Patients with NVE and PVE treated with regimens that included daptomycin at different dosages (daptomycin-containing regimens, DCR) were compared with those treated with non-DCR. Primary endpoints of the study were 30-day mortality and clinical treatment failure. During the study period, 327 patients with Gram-positive NVE (n = 224, 68.8%) or PVE (n = 103, 31.2%) were analysed. Eighty-four (37.5%) NVE patients were treated with daptomycin, alone (59.9%) or with other antimicrobials. Most PVE patients (n = 61, 58%) were treated with a DCR, which always consisted of daptomycin plus other drugs. Among PVE patients, treatment with a DCR was associated with lower 30-day mortality than treatment with a non-DCR (6.5% vs. 38%, P < 0.001). Among NVE patients treated with DCRs, risk factors for 30-day mortality were streptococcal infections, persistent bacteraemia, and standard-dose (4-6 mg/kg) rather than high-dose daptomycin therapy. Overall, surgical treatment of IE and DCR were associated with clinical success and 30-day survival. Compared with non-DCRs, using single-drug or multiple-drug DCRs is associated with lower 30-day mortality in PVE, but with higher 30-day mortality in NVE at approved doses and in a subgroup of streptococcal IE.