Treatment Of Infective Endocarditis Research Articles

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

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

Is a Negative Transesophageal Echocardiogram Enough to Stop Treatment?

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

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

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

Minimally Invasive Mitral Valve Surgery for Mitral Valve Infective Endocarditis.

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

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

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

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

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

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

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

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

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

Etiología de la insuficiencia renal en pacientes con endocarditis infecciosa. Papel de los antibióticos

Background and objectivesThe possible renal toxicity of certain antibiotics (AB) is well known. The objective of our work is to know the possible effect of AB treatments in the development of renal failure (RF) in patients with infective endocarditis (IE). Material and methodCollection from a national multi-centre registry of collection on renal function, both prior and its impairment, if any, during the treatment of IE and in relation to possible causative factors, including the use of AB. ResultsBetween 2008 and 2012, 1,853 episodes of IE reported from 26 Spanish centres were analysed. Of these, 21.6% had prior RF. They developed new RF or impairment of renal function in 38.7% of the cases. In patients with prior RF, impairment was more frequent (64 vs. 31.7%, P<.001). Overall, patients with RF were older (70.6 vs. 67 years, P<.01), had more comorbidities (Charlson index 5 vs. 4, P<.01), and IE by Staphylococcus aureus (32.1 vs. 16.5%, P<.01). Potentially nephrotoxic AB use was only associated with RF in patients without prior RF (aminoglycosides: OR=1.47 [95% CI 1.096-1.988], P=.010; aminoglycosides with vancomycin: OR=1.49 [95% CI 1.069-2.09], P=.019). ConclusionsIn patients without prior RF, the use of nephrotoxic AB is associated with impairment of renal function. In patients with RF prior to the IE episode, impairment of renal function was more frequent but appears to be more related to the severity of infection.

Old antimicrobials and Gram-positive cocci through the example of infective endocarditis and bone and joint infections.

The management of some serious infections such as infective endocarditis (IE) and bone and joint infections (BJIs) caused by Gram-positive cocci (GPC) is complex and requires great responsiveness and effective antimicrobials with high bioavailability in heart valves or bone tissues. Treatment of these infections requires the use of a higher dosage that may result in increased toxicity or the use of new promising antimicrobials to control the infection. However, use of these new antimicrobials could still bring about new toxicity and resistance. Another approach may be the 'comeback' of old antimicrobials, which is evaluated in this review in the treatment of IE and BJIs caused by GPC.

Value of surgery for infective endocarditis in dialysis patients

ObjectivesTo determine the value of surgery for infective endocarditis (IE) in patients on hemodialysis by comparing the nature and invasiveness of endocarditis in hemodialysis and nonhemodialysis patients and their hospital and long-term outcomes, and identifying risk factors for time-related mortality after surgery. MethodsFrom January 1997 to January 2013, 144 patients on chronic hemodialysis and 1233 nonhemodialysis patients underwent valve surgery for IE at our institution. Propensity matching identified 99 well-matched hemodialysis and nonhemodialysis patient pairs for comparison of outcomes. ResultsStaphylococcus aureus infection was more common in hemodialysis patients than in nonhemodialysis patients (42% vs 21%; P < .0001), but invasive disease was similar in the 2 groups (47%; P = .3). Hospital mortality was 13% and 5-year survival was 20% for hemodialysis patients, 20% below that expected in a general hemodialysis population but 15% above that of hemodialysis patients treated nonsurgically for IE. For matched patients, hospital mortality was 13% for hemodialysis patients versus 5.1% for nonhemodialysis patients (P = .05), and survival at 1 and 5 years was 56% versus 83% and 24% versus 59%, respectively (P < .004). Use of an arteriovenous graft for dialysis access (P = .01) and preoperative placement of a pacemaker (P < .0001) were risk factors for late mortality in hemodialysis patients. For matched patients, freedom from reoperation was similar in the hemodialysis and nonhemodialysis groups (P > .9). ConclusionsIntermediate-term survival after surgery for IE in hemodialysis patients is substantially worse than that in nonhemodialysis patients, but only slightly worse than that in the general hemodialysis population and substantially better than that in hemodialysis patients with IE treated nonsurgically, supporting continued surgical intervention for IE.

International experts' practice in the antibiotic therapy of infective endocarditis is not following the guidelines

ObjectiveThe management of infective endocarditis (IE) may differ from international guidelines, even in reference centres. This is probably because most recommendations are not based on hard evidence, so the consensus obtained for the guidelines does not represent actual practices. For this reason, we aimed to evaluate this question in the particular field of antibiotic therapy. MethodsThirteen international centres specialized in the management of IE were selected, according to their reputation, clinical results, original research publications and quotations. They were asked to detail their actual practice in terms of IE antibiotic treatment in various bacteriological and clinical situations. They were also asked to declare their IE-related in-hospital mortality for the year 2015. ResultsThe global compliance with guidelines concerning antibiotic therapy was 58%, revealing the differences between theoretical ‘consensus’, local recommendations and actual practice. Some conflicts of interest were also probably expressed. The adherence to guidelines was 100% when the protocol was simple, and decreased with the seriousness of the situation (Staphylococus spp. 54%–62%) or in blood-culture-negative endocarditis (0%–15%) that requires adaptation to clinical and epidemiological data. ConclusionWorldwide experts in IE management, although the majority of them were involved and co-signed the guidelines, do not follow international consensus guidelines on the particular point of the use of antibiotics.

Abstract TMP87: Early Surgery for Infective Endocarditis with Stroke Does Not Increase Post-operative Neurological Complications: What are We Waiting For?

Introduction: Ischemic and hemorrhagic stroke often complicate infective endocarditis (IE). Optimal timing of surgical intervention for IE with stroke remains controversial. We compared neurological outcomes of early and delayed valve surgery for IE complicated by stroke. Methods: We reviewed 73 patients with acute IE by Duke Criteria who underwent brain imaging (CT, MRI, or cerebral angiogram) before valve operations between December 2014 and August 2016. Date of IE diagnosis was defined as date of antibiotic initiation. Early surgery was defined as valve replacement ≤14 days from date of IE diagnosis and delayed surgery as &gt;14 days. Neurological complication is defined as delirium &gt;72 hours after extubation and cessation of sedation, new ischemic or hemorrhagic stroke. Results: Among 73 patients who underwent valve replacement surgery, 71 had evidence of stroke on imaging: 54 patients with acute or subacute ischemic infarct, 9 patients with evidence of intracerebral hemorrhage, and 8 patients with subarachnoid hemorrhage. The median time from IE diagnosis to surgery was 9 days. Forty patients had early surgery, and 33 patients had late surgery. Early surgery group had fewer patients with history of ischemic stroke (55% vs 79%, p=0.033), fewer acute or subacute infarcts on imaging (63% vs 88% p=0.016), but more native valve infections (73% vs 45%, p=0.018). The incidence of post-operative stroke was similar between both groups (2.5% vs 9%, p=0.32). In the delayed group, ischemic strokes occurred in 4 patients awaiting surgery. Hypertension and diabetes mellitus were associated with post-operative neurological complications (p&lt;0.05), but pre-operative stroke on imaging was not. Conclusion: In IE patients with acute stroke, early surgery does not appear to increase post-operative neurological complications.

Single Centre Review of Surgically Managed Infective Endocarditis

Purpose: Infective endocarditis (IE) is a life-threatening illness that requires early intervention. We sought to identify the outcomes of all patients who underwent surgical intervention for IE at an Australian tertiary hospital. Methodology: The study institution's Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database was searched for all patients who underwent valve surgery with active IE between 2000 and 2015. Additional data was obtained by reviewing medical records. Results: There were 133 patients who underwent surgical management of IE. Mean patient age was 54 ± 16 years. A history of IV drug use was present in 23% (31/133) of patients. The commonest infective agents were Staphylococcus aureus in 32% (42/133), of which 14% were MRSA (6/42), Streptococcus viridans in 15% (20/133), and Enterococcus faecalis in 13% (17/133). A single valve procedure was performed in 75% (100/133), while multiple valve procedures were performed in 25% (33/133). The surgical procedures were: aortic valve surgery in 68% (90/133), mitral valve surgery in 47% (63/133) and tricuspid valve surgery in 10% (13/133). Surgical mortality was 15% (20/133). On univariate analysis having emergency surgery (p = 0.003), cross clamp time (p = 0.015) and cardiopulmonary bypass time (p = 0.03) were identified as significant risk factors for mortality. On multivariable analysis emergency surgery (p = 0.021) was identified as a significant risk factor for mortality. Conclusion: Surgery for infective endocarditis is associated with substantial early mortality. Emergency surgery is associated with increased risk of mortality. A multidisciplinary approach with early referral to cardiothoracic surgery is indicated.

Daptomycin in Left Sided Endocarditis: A Single Center Experience

Infective endocarditis (IE) carries a high risk of cardiac morbidity and mortality, despite advances in the contemporary armamentarium. Along with the development of antibiotic resistant strains, research focusing on the efficacy of novel agents other than standard antibiotic regimens continues. Daptomycin, one of these antibiotics, is approved for the treatment of Staphylococcus bacteremia and right-sided endocarditis. This retrospective study was an investigation of the effectiveness of daptomycin in patients with left-sided IE. Fourteen patients (mean age 50.9±16.5; range 24 to 70 years) with the diagnosis of left-sided IE based on modified Duke criteria received daptomycin as monotherapy. Outcome was evaluated according to clinical improvement, microbiological eradication, and in-hospital mortality. Blood culture was positive in 13 patients (92.8%) and staphylococci were isolated in all but 1 patient (92.3%). Daptomycin was administered as monotherapy at a dose of 6 or 8 mg/kg/day for mean of 40.6±4.4 days. Clinical recovery rate was 71.4% and microbiological eradication rate was 85.7%. Mean duration of clinical recovery was 8.7±3.2 days and duration of microbiological eradication was 11.1±3.6 days. Side effects developed in 6 patients, but drug discontinuation was not required in any patient. Ten patients improved without complications. Two patients were lost due to heart failure and multiple-organ failure while treatment was continuing, and 2 patients died in early cardiac postoperative period. Daptomycin is an effective and safe alternative to standard antibiotic therapy for the treatment of left-sided IE.

Characteristics of Infective Endocarditis in a Tertiary Hospital in East China.

The epidemiology, clinical presentation, and treatment of infective endocarditis (IE) has significantly changed over the past few years in developed countries. However, relevant data from developing countries are different and remain scarce. The objective of this study was to evaluate the clinical presentations, treatment and outcomes of IE patients in a tertiary hospital in East China over an 8-year period. This was a retrospective observational study of consecutive cases of definite or possible IE as per the modified Duke criteria between January 2008 and December 2015. A total of 135 definite and 39 probable IE cases were identified. The mean age was 47.8 ± 15.7 years, with a male preponderance (1.9: 1). Degenerative valve disease accounted for 30.5% cases of IE, followed by congenital heart disease (29.9%) and rheumatic heart disease (14.9%). Native cardiac valves were present in 93.7% of the IE patients. Echocardiography and blood culture were performed in all patients, of whom 55.2% were found to have large vegetations (≥10 mm) and the positive rate of blood culture was 60.3%. Streptococcus remained the chief causative agent that was identified in 61.9% of culture-positive patients. Glycopeptide antibacterials and cephalosporins were the most frequently used antimicrobial drugs for IE therapy. Seventy-six (43.7%) of the IE patients were surgically treated. The mortality rate during hospital stay was 10.9%. Our data reflected clinical and microbiological profile, and treatment of IE in a tertiary hospital located in the East China.

Antibacterial therapy at different stages of treatment of infectious endocarditis. Do we act correctly?

To study characteristics of antibacterial therapy (ABT) at different stages of treatment of patients with infective endocarditis (IE) in clinical practice. In retrospective (2001 to 2008) and prospective (2008 to 2014) studies lasting 14-years, 302 hospitalized patients with confirmed native valve IE were given antibiotic therapy at outpatient and inpatient stages of treatment. The choice of antibacterial drugs, duration and side effects of prolonged use of antibiotics (AB) were analyzed in comparison with the results of hospital treatment of patients with IE. It was shown that outpatients with IE due to fever without a specific diagnosis, were frequently prescribed short courses of antibiotics with the prevalence of ceftriaxone monotherapy and its combination with aminoglycosides as the starting treatment under hospital conditions. The cases of incompliance with the recommended duration of antimicrobial therapy were documented. The most common side effects of AB included diarrheal disorders, but the most serious problem was nephrotoxicity resulting in total or partial withdrawal of ABT. The potential of antibiotic treatment of IE is employed but incompletely, the main obstacles to the implementation of adequate antibiotic therapy of IE being the low rate of early diagnosis of the disease including etiological one and the unacceptable level of long-term safety of ABT for the patients.

Optimal timing for early surgery in infective endocarditis: a meta-analysis.

To systematically review early surgery and the optimal timing of surgery in patients with infective endocarditis (IE), a search for foreign and domestic articles on cohort studies about the association between early surgery and infective endocarditis published from inception to January 2015 was conducted in the PubMed, EMBASE, Chinese Biomedical Literature (CBM), Wanfang and Chinese National Knowledge Infrastructure (CNKI) databases. The studies were screened according to the inclusion and exclusion criteria, the data were extracted and the quality of the method of the included studies was assessed. Then, the meta-analysis was performed using the Stata 12.0 software. Sixteen cohort studies, including 8141 participants were finally included. The results of the meta-analysis revealed that, compared with non-early surgery, early surgery in IE lowers the incidence of in-hospital mortality [odds ratio (OR) = 0.57, 95% confidence interval (CI) (0.42, 0.77); P = 0.000, I(2) = 73.1%] and long-term mortality [OR = 0.57, 95% CI (0.43, 0.77); P = 0.001, I(2) = 67.4%]. Further, performing operation within 2 weeks had a more favourable effect on long-term mortality [OR = 0.63, 95% CI (0.41, 0.97); P = 0.192, I(2) = 39.4%] than non-early surgery. In different kinds of IE, we found that early surgery for native valve endocarditis (NVE) had a lower in-hospital [OR = 0.46, 95% CI (0.31, 0.69); P = 0.001, I(2) = 73.0%] and long-term [OR = 0.57, 95% CI (0.40, 0.81); P = 0.001, I(2) = 68.9%] mortality than the non-early surgery group. However, for prosthetic valve endocarditis (PVE), in-hospital mortality did not differ significantly [OR = 0.83, 95% CI (0.65, 1.06); P = 0.413, I(2) = 0.0%] between early and non-early surgery. We concluded that early surgery was associated with lower in-hospital and long-term mortality compared with non-early surgical treatment for IE, especially in NVE. However, the optimal timing of surgery remains unclear. Additional larger prospective clinical trials will be required to clarify the optimal timing for surgical intervention and determine its efficacy in PVE.

Clinical experience of infective endocarditis complicated by acute cerebrovascular accidents

To evaluate the clinical results of patients with infective endocarditis (IE) complicated by acute cerebrovascular accidents (CVAs). A total of 44 patients with IE complicated by CVA at admission were retrospectively analyzed in a single medical institute from 2005 to 2011. At the time of admission, 18 patients were diagnosed with hemorrhagic stroke, and 26 patients were diagnosed with ischemic stroke. Fifteen patients received surgical intervention during hospitalization. The hospital mortality rate was 38.9% for the hemorrhagic stroke group and 42.3% for the ischemic stroke group (p=0.821). The mortality rate was 33.3% for the surgical group and 44.8% for the nonsurgical group (p=0.531). At 30 days of hospitalization, 45.8% of the patients experienced an adverse event (defined as death due to organ failure, restroke, cardiogenic shock, or septic shock during the treatment period), and the attrition rate was 1.5% per day. Surgery performed after the adverse events increased mortality (80.0%) compared with surgery performed on patients with no adverse events (10.0%; p=0.017). A Cox regression analysis revealed that creatinine > 2mg/dL, diabetes, and staphylococcal infection were the risk factors of the adverse events. Early surgical intervention for IE with ischemic stroke may prevent adverse events, particularly in patients with impaired renal function, diabetes, or staphylococcal infection. A delay in operation of > 30 days is recommended after hemorrhagic stroke.

How do physicians cope with controversial topics in existing guidelines for the management of infective endocarditis? Results of an international survey

International guidelines are available to help physicians prescribe appropriate antibiotic regimens to patients with infective endocarditis (IE). However some topics of these guidelines are controversial. We conducted an international survey to assess physicians' adherence to these guidelines, focusing on these controversial items. An invitation to participate to a 15-question online survey was sent in 2012–2013 to European Society of Clinical Microbiology and Infectious Diseases (ESCMID) members, scientific societies and corresponding authors of publications on IE mentioned in PubMed from 1990 to 2012, inclusive. Eight hundred thirty-seven physicians participated in the survey, and 625 (74.7%) completed it over the first question. The results showed great heterogeneity of practices. Claiming to follow guidelines was marginally associated with more guideline-based strategies. Gentamicin use depended on causative pathogens (p <0.001) and physician specialty (p 0.02). Eighty-six per cent of the physicians favoured vancomycin alone or in combination with gentamicin or rifampicin as a first-line treatment for left-sided native valve methicillin-resistant Staphylococcus aureus IE, 31% considered switching to oral therapy as a therapeutic option and 33% used the ampicillin and ceftriaxone combination for enterococcal IE as a first-line therapy. Physician specialty significantly affected the choice of a therapeutic strategy, while practicing in a university hospital or the number of years of practice had virtually no impact. Our survey, the largest on IE treatment, underscores important heterogeneity in practices for treatment of IE. Nonetheless, physicians who do not follow guidelines can have rational strategies that are based on the literature. These results could inform the revision of future guidelines and identify unmet needs for future studies.