Diagnosis and management of infective endocarditis and its complications

Endocarditis and associated complications

Echocardiography is a most useful bedside tool to help in the diagnosis and subsequent management of patients with infective endocarditis. Transesophageal echocardiography provides complementary and often incremental information necessary in making a diagnosis, and in identifying associated intracardiac complications. This chapter will focus on the role of echocardiography in the diagnosis and management of infective endocarditis.

Candida dubliniensis in Recurrent Polymicrobial Tricuspid Endocarditis

This report describes a successful operative case of tricuspid infective endocarditis in an IV drug user. Despite cessation of IV drug use, there were further recurrences. Six different microorganisms with multiple portals of entry were identified, including one episode of fungal endocarditis, To our knowledge, this is the first case of recurrent infective endocarditis involving Candida dubliniensis in an HIV-negative patient.

Epidemiology and clinical outcomes of infective endocarditis in hemodialysis patients

BACKGROUND

Infective endocarditis is one of the most serious complications of bacteremia in patients undergoing chronic hemodialysis and is more frequent than previously recognized. The aim of our study was to describe the clinical characteristics, outcome, and factors predicting mortality of infective endocarditis in hemodialysis patients.

METHODS

In this retrospective review, all patients on chronic hemodialysis admitted to a 600-bed urban teaching hospital with infective endocarditis over a 15-year period (1990 to 2004), were identified using discharge codes. Modified Duke criteria were retrospectively applied, and patients fulfilling the criteria for definite endocarditis were included in the study.

RESULTS

Sixty-nine patients on hemodialysis with definite endocarditis were identified. The predominant type of vascular access was double-lumen catheter (66.7%). The mean duration of dialysis was 37 +/- 32 months. The predominant organism was Staphylococcus aureus (57.9%), of which 57.5% were methicillin susceptible. The most frequently infected valve was mitral (49.3%), followed by aortic (21.7%) and tricuspid (10.1%) valves. The cardiac and neurologic complication rates were 40.6% and 37.7%, respectively. Fifteen patients underwent valvular heart surgery. The overall in-hospital mortality was 49.3% (34 of 69). More patients who had surgery survived than patients who did not (12 of 15 versus 23 of 54; p = 0.018, odds ratio = 5.39, 95% confidence interval: 1.3 to 17.6). On logistic regression, valve surgery was the only independent factor predicting survival (p = 0.023).

CONCLUSIONS

The prognosis of infective endocarditis in hemodialysis patients is poor, with surgery serving as an independent predictor of survival.

Endocarditis neumocócica en niño de 17 meses previamente sano

Invasive pneumococcal infection is a severe disease and its incidence may be increasing. Endocarditis due to Streptococcus pneumoniae is uncommon, particularly in children without risk factors. Etiologic diagnosis is difficult when cultures are negative. We report the case of a previously healthy, 17-month-old boy not vaccinated against pneumococcus who, during the course of pneumonia treated with beta-lactam antibiotics, developed cardiorespiratory deterioration and heart murmur. Mitral valve vegetation was identified by transthoracic echocardiography. Endocarditis was diagnosed and new antibiotics were given for 6 weeks (cefotaxime, gentamycin and vancomycin). Cultures were negative. Because of lack of improvement, prosthetic mitral replacement was indicated. S. pneumoniae was identified by polymerase chain reaction (PCR) in the pathological specimen. Outcome was favorable, and the patient remained symptom-free after 6 months of follow-up. The possibility of endocarditis as an invasive pneumococcal infection should be considered in children without risk factors. PCR is a useful technique to establish the etiology when cultures are negative.

Prospective study of bacteremia and complications With EUS FNA of rectal and perirectal lesions

BACKGROUND & AIMS

Recent studies showed that endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a low-risk procedure for causing bacteremia and infectious complications when sampling solid lesions of the upper gastrointestinal (GI) tract. As a result, antibiotics are not recommended for prophylaxis against endocarditis. Our aim was to prospectively evaluate the risk of bacteremia and other infectious complications in patients undergoing EUS FNA of lower GI tract lesions.

METHODS

Patients referred for EUS FNA of lower GI tract lesions were considered for enrollment. Patients were excluded if there was an indication for preprocedure antibiotic administration based on American Society for Gastrointestinal Endoscopy guidelines, had taken antibiotics within the prior 7 days, or if they had a cystic lesion. Blood cultures were obtained immediately before the procedure, after flexible sigmoidoscopy/radial EUS, and 15 minutes after EUS FNA.

RESULTS

One hundred patients underwent a total of 471 FNAs (mean, 4.7 FNAs/patient; range, 1-10 FNAs/patient). Blood cultures were positive in 6 patients. Cultures from 4 patients (4.0%, 95% confidence interval, 1.6%-9.8%) grew coagulase-negative Staphylococcus (n = 2), Peptostreptococcus stomatis (n = 1), or Moraxella (n = 1), which were considered contaminants. Two patients (2.0%, 95% confidence interval, 0.6%-7%) developed bacteremia: Bacteroides fragilis (n = 1) and Gemella morbillorum (n = 1). No signs or symptoms of infection developed in any patient.

CONCLUSIONS

EUS FNA of solid lesions in the lower GI tract should be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics for the prevention of bacterial endocarditis.

Treatment of Endocarditis: A Decade of Experience

BACKGROUND

Endocarditis represents a small proportion of cardiovascular disease but is associated with high mortality. Previous studies have reported a range of outcomes, and determinants of mortality remain poorly defined.

METHODS

The goal of this retrospective study was to identify independent variables for early and late mortality in 364 consecutive patients with endocarditis over a 10-year period.

RESULTS

The mean age of patients was 48.2 years, 35% had a history intravenous drug use, 19.8% were reoperative, and 93% had native valve endocarditis. Fever (68%) and fatigue (36%) were the most common presenting symptoms, and congestive heart failure (52%), embolization (45%), and uncontrolled sepsis (36%) were the most common indications for surgery. Overall survival at discharge, 1, 5, and 10 years was 87%, 76%, 55%, and 31%, respectively. Survival at discharge, 5, and 10 years was 91%, 69%, and 41% for surgical patients and 85%, 60%, and 31% for medically treated patients, respectively. Surgery was associated with improved short-term and long-term survival (p < 0.0.01). Independent predictors of early death were hemodynamic instability (p = 0.013) and age older than 55 years (p < 0.025). Medical treatment (p = 0.005), age older than 55 years (p = 0.032), institution (p < 0.001), New York Heart Association functional class III or IV (p = 0.002), and hemodynamic instability (p = 0.044) were predictive of late death.

CONCLUSIONS

Short-term and long-term mortality from endocarditis remains high, although surgically treated patients had improved survival. Differing outcomes from two geographically similar institutions highlight the limitations of extrapolating risk factors between disparate patient populations.

Diagnostic value of harmonic transthoracic echocardiography in native valve infective endocarditis: comparison with transesophageal echocardiography

Background

Although echocardiography has been incorporated into the diagnostic algorithm of patients with suspected infective endocarditis (IE), systematic usage in clinical practice remains ill defined. To determine the diagnostic accuracy of detecting vegetations using harmonic transthoracic echocardiography (hTTE) as compared to transesophageal echocardiography (TEE) in patients with an intermediate likelihood of native valve IE.

Methods

Between 2004 and 2005, 36 consecutive inpatients with an intermediate likelihood of disease were prospectively evaluated by hTTE and TEE.

Results

Of 36 patients (21 males with a mean age of 57 ± 15 years, range 32 to 86 years), 19 patients had definite IE by TEE. The sensitivity for the detection of vegetations by hTTE was 84%, specificity of 88%, positive predictive value (PPV) of 89% and negative predictive value (NPV) of 82%. The association between hTTE and TTE interpretation for the presence and absence of vegetations were high (kappa = 0.90 and 0.85 respectively).

Conclusion

In patients with an intermediate likelihood of native valve IE, TTE with harmonic imaging provides diagnostic quality images in the majority of cases, has excellent concordance with TEE and should be recommended as the first line test.

Complexity and subtlety of infective endocarditis

Infective endocarditis (IE) is an uncommon clinical entity that, if unrecognized, leads to serious morbidity and mortality. Approximately 15,000 new cases of IE occur in the United States each year. Despite advances in early diagnosis, antimicrobial treatment, and surgical techniques, reported mortality from referral centers has changed little throughout several decades. Early recognition of IE requires understanding of its epidemiology, risk factors, clinical presentations, physical examination signs, microbiological associations, and electrocardiographic and chest radiographic findings. Once IE is suspected, further testing with blood cultures and echocardiography can confirm the diagnosis and lead to early treatment with bactericidal antibiotics and surgery when appropriate, thus reducing the morbidity and mortality of IE. Unrecognized and untreated, IE is invariably fatal. Early recognition of IE and an in-depth understanding of the clinical vagaries of IE are mandatory for all patient care providers.

Prognostic stratification of patients with left-sided endocarditis determined at admission

BACKGROUND

The prognosis of patients with left-sided endocarditis remains poor despite the progress of surgical techniques. Identification of high-risk patients within the first days after admission to the hospital would permit a more aggressive therapeutic approach.

METHODS

We designed a prospective multicenter study to find out the clinical, microbiologic, and echocardiographic characteristics available within 72 hours of admission that might define the profile of high-risk patients. Of 444 episodes, 317 left-sided endocarditis cases were included and 76 variables were assessed. Events were surgery in the active phase of the disease and in-hospital death. A stepwise logistic regression analysis was undertaken to determine variables predictive of events.

RESULTS

Multivariate analysis of the clinical variables found to have statistical significance in the univariate analysis identified the following as predictive: patient referred from another hospital (odds ratio [OR]: 1.8; confidence interval [CI], 1.1-2.9), atrioventricular block (OR: 2.5; CI, 1.1-5.9), acute onset (OR: 1.7; CI, 1.1-2.9), and heart failure at admission (OR: 2.3; CI, 1.4-3.8). When the echocardiographic and microbiological variables statistically significant in the univariate analysis were introduced, the presence of heart failure at admission (OR: 2.9; CI, 1.8-4.8), periannular complications (OR: 1.8; CI, 1.1-3.1), and Staphylococcus aureus infection (OR: 2.0; CI, 1.1-3.8) retained prognostic power. Risk could be accurately stratified when combining the 3 variables with predictive power: 0 variables present: 25% of risk; 1 variable present: 38% to 49% of risk; 2 variables present: 56% to 66% of risk; and 3 variables present: 79% of risk.

CONCLUSIONS

The risk of patients with left-sided endocarditis can be accurately stratified with the assessment of variables easily available within 72 hours of admission to the hospital.

Epidemiology of infective endocarditis in Tunisia: a 10-year multicenter retrospective study

BACKGROUND

Since the first description of infective endocarditis, the profile of the disease has evolved continuously with stable incidence. However, epidemiological features are different in developing countries compared with western countries.

OBJECTIVE

To describe epidemiological, microbiological and outcome characteristics of infective endocarditis in Tunisia.

PATIENTS AND METHODS

This was a descriptive multicenter retrospective study of inpatients treated for infective endocarditis from 1991 to 2000. Charts of patients with possible or definite infective endocarditis according to the Duke criteria were included in the study.

RESULTS

Four hundred and forty episodes of infective endocarditis among 435 patients (242 males, 193 females; mean (SD) age=32.4 (16.8) years, range 1-78 years) were reviewed. The most common predisposing heart disease was rheumatic valvular disease (45.2%). Infective endocarditis occurred on prosthetic valves in 17.3% of cases. Causative microorganisms were identified in 50.2% of cases: streptococci (17.3%), enterococci (3.9%), staphylococci (17.9%), and other pathogens (11.1%). Blood cultures were negative in 53.6% and no microorganism was identified in 49.8%. Early valve surgery was performed in 51.2% of patients. The in-hospital mortality was 20.6%.

CONCLUSION

Infective endocarditis is still frequently associated with rheumatic disease among young adults in Tunisia, with a high frequency of negative blood cultures and high in-hospital mortality, given that the population affected is relatively young.

Treatment of Brucella endocarditis: our surgical experience with 6 patients

BACKGROUND

Endocarditis is a rare but life-threatening complication of brucellosis. Its mortality rate has recently been reduced with the use of combined medical and surgical treatment.

METHODS

Between March 2002 and April 2004, 6 patients with Brucella endocarditis underwent surgery at the Siyami Ersek Cardiovascular Center in Istanbul, Turkey. The diagnosis of Brucellosis was based on the presence of clinical signs and symptoms compatible with brucellosis, serology and/or a positive blood culture. All patients with suspected Brucella endocarditis were studied by echocardiography. The diagnosis of Brucella endocarditis was made in accordance with Duke's criteria.

RESULTS

The most commonly affected valve was the aortic valve (4 patients). Four patients had prosthetic valves because of a previous history of rheumatic fever. In 5 patients, elective surgery was performed. Five patients underwent valve replacement with prosthetic valves, but 1 patient underwent excision of the abscess cavity without valve replacement. There was no operative mortality. All patients continued antibiotic treatment for at least 3 months postoperatively. The median duration of follow-up after surgery was 12 months. During the follow-up period, 1 patient died, while the others remained alive with no recurrences.

CONCLUSION

Prosthetic valve replacement is a safe procedure in patients with Brucella endocarditis. Surgical interventions combined with triple antibiotic therapy yield good results with no recurrence in the long-term follow-up.

Early Surgery in Patients with Infective Endocarditis: A Propensity Score Analysis

BACKGROUND

An accurate assessment of the predictors of long-term mortality in patients with infective endocarditis is not possible using retrospective data because of inherent treatment biases and predictable imbalances in the distribution of prognostic factors. Largely because of these limitations, the role of surgery in long-term survival has not been adequately studied.

METHODS

Data were collected prospectively from 426 patients with infective endocarditis. Variables associated with surgery in patients who did not have intracardiac devices who had left-side-associated valvular infections were determined using multivariable analysis. Propensity scores were then assigned to each patient based on the likelihood of undergoing surgery. Using individual propensity scores, 51 patients who received medical and surgical treatment were matched with 51 patients who received medical treatment only.

RESULTS

The following factors were statistically associated with surgical therapy: age, transfer from an outside hospital, evidence of infective endocarditis on physical examination, the presence of infection with staphylococci, congestive heart failure, intracardiac abscess, and undergoing hemodialysis without a chronic catheter. After adjusting for surgical selection bias by propensity score matching, regression analysis of the matched cohorts revealed that surgery was associated with decreased mortality (hazard ratio, 0.27; 95% confidence interval, 0.13-0.55). A history of diabetes mellitus (hazard ratio, 4.81; 95% confidence interval, 2.41-9.62), the presence of chronic intravenous catheters at the beginning of the episode (hazard ratio, 2.65; 95% confidence interval, 1.31-5.33), and paravalvular complications (hazard ratio, 2.16; 95% confidence interval, 1.06-4.44) were independently associated with increased mortality.

CONCLUSIONS

Differences between clinical characteristics of patients with infective endocarditis who receive medical therapy versus patients who receive surgical and medical therapy are paramount. After controlling for inherent treatment selection bias and imbalances in prognostic factors using propensity score methodology, risk factors associated with increased long-term mortality included diabetes mellitus, the presence of a chronic catheter at the onset of infection, and paravalvular complications. In contrast, surgical therapy was associated with a significant long-term survival benefit.

[Role of transoesophageal echocardiography in bacteremia caused by Staphylococcus aureus]

Treatment and prognosis of bacteremias caused by Staphylococcus aureus is different, whether only bacteremia is present or it is complicated with endocarditis. Transoesophageal echocardiography may have a role in evaluation of bacteremias caused by Staphylococcus aureus to confirm or exclude infective endocarditis. The aim of this study was to characterize patients with infective endocarditis.

PATIENTS AND METHOD

We reviewed the patients studied with transoesophageal echocardiography at our institute between October 1988 and March 2002. The reason for transoesophageal echocardiography was bacteremia caused by Staphylococcus aureus. A total of 24 patients data were analyzed, 15 male and 9 female. Suspicion of infective endocarditis was in 11 patients with native valves, in 8 patients early after prosthetic valve implantation, in 2 patients late after prosthetic valve implantation and in 3 patients after pacemaker implantation. Patient's data were analyzed retrospectively.

RESULTS

Thirteen patients had infective endocarditis and 7 of them had community acquired infection. Native valve, prosthetic valve and left ventricular thrombus were the infected tissues. Vegetation was present in 11 patients, one of them was infection of the left ventricular thrombus. Paravalvular leak was found in 3 patients and abscess in 2. Three out of 7 patients with native valve infective endocarditis presented on a structurally normal valve. Eleven patients had no infective endocarditis, in 9 of them there was nosocomial bacteremia. Surgery was performed in 8 patients with infective endocarditis: 3 with acute, 3 with subacute and 2 with late infection. Two patients died after surgery, one of them had acute infection. Four medically treated patients were cured and one died. From the 11 patients without infective endocarditis 7 were cured and 4 died. At the autopsy infective endocarditis was diagnosed in one out of 4 patients. Transoesophageal echocardiography was performed in this patient 4 weeks before death.

CONCLUSION

The authors' date suggest, that transoesophageal echocardiography is the diagnostic tool for differentiation between bacteremia and infective endocarditis. The infective endocarditis in both community acquired and nosocomial Staphylococcus aureus bacteremia can cause infective endocarditis on native valves, in thrombus and on intracardiac materials.

Clinicopathological conference: case report--a case of anorexia and weak arm

The authors present the case of a 49-year-old female who presented to the emergency department with a chief complaint of "not eating well." She was found to have a heart murmur, a focal neurological deficit, and large mitral valve vegetation. The patient was later diagnosed with acute Pseudomonal endocarditis with septic emboli to the brain, liver, spleen, and kidneys. A discussion of the patient presentation, diagnostic evaluation, and outcome are reviewed.

Developing a plan of care using the Roper, Logan and Tierney model

This care study, using the Roper, Logan and Tierney Model of Nursing, examines the presentation of a patient with a history of drug misuse and a current diagnosis of infective endocarditis and hepatitis C. While this particular model of nursing incorporates 12 activities of daily living, this care study will deal with three specific activities: maintaining a safe environment, communication and breathing. One of the main concerns arising from this care study was the inadequate management of pain for the patient. It is suggested in the literature that healthcare professionals do not always adequately address pain management, primarily because of fear of causing addiction. The authors suggest that the patient's history of drug misuse in this study may have further mitigated against him receiving adequate pain control.

Left atrial myxoma and mitral valve endocarditis--a cause and effect: a case report

We report the case of a 55-year-old man who presented with an infected left atrial myxoma that seeded a normal native mitral valve. Despite the absence of mitral regurgitation or heart failure, prior to the patient completing a course of IV antibiotic therapy we removed the tumor, replaced the mitral valve, and added 3 coronary artery bypass grafts, following a single embolic event. Although a completed course of antibiotic therapy may have allowed preservation of the native mitral valve, we believed that the risk of recurrent embolization from either the mass or the mitral valve vegetations was greater that the long-term risks of valve replacement.

Cardioembolic stroke

Cardiac sources of emboli account for over one quarter of all ischemic strokes. Strokes due to cardioembolism are in general severe and prone to early and long-term recurrence. Nonvalvular atrial fibrillation remains the most common cause of cardioembolic stroke. Despite the proven efficacy of oral anticoagulation, it is prescribed for less than half of the patients with risk factors for embolism and no contraindications for anticoagulation. The embolic risk of patent foramen ovale is low except when combined with an atrial septal aneurysm. Aortic arch atheroma as an independent risk factor for ischemic stroke is the subject of ongoing debate. As the risk of embolism is heterogeneous for the various potential cardioembolic conditions, accurate definition of stroke mechanism is very important to guide the most effective therapy.

Successful treatment of polymicrobial multivalve infective endocarditis

A 57-year-old man presented with triple valve infective endocarditis. There were vegetations on the tricuspid, mitral, and aortic valve. He had multiple complications such as pulmonary abscess, severe anaemia, and congestive heart failure. His general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and inotropic support, allowed him to tolerate surgery. Triple valve replacement was successfully performed without major complication. Vegetation cultures grew Streptococcus bovis and Enterecoccus faecalis. At 1 year follow-up, the patient is alive in NYHA functional class I.

Periannular complications in infective endocarditis involving native aortic valves

The extension of infection in native valve infective endocarditis (IE) from valvular structures to the periannular tissue is incompletely understood. It is unknown, for example, whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinct clinical characteristics of patients with aortocavitary fistulae and nonruptured abscesses in native valve IE and to evaluate the impact of fistulization on the outcomes of patients with native aortic valve IE complicated with periannular lesions. In a retrospective multicenter study of 2,055 native valve IE episodes, 201 patients (9.8%) with periannular complications in aortic valve IE were identified (46 with aortocavitary fistulization and 155 with nonruptured abscesses). Rates of heart failure (p = 0.07), ventricular septal defect (p <0.001), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 172 patients (86%), and in-hospital mortality in the overall population was 29%. Multivariate analysis identified age >60 years (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.3 to 5.2), renal failure (OR 3.0, 95% CI 1.5 to 6.0), and moderate or severe heart failure (OR 2.5, 95% CI 1.2 to 5.2) as independent risk factors for death. There was a trend toward increased in-hospital mortality in patients with aortocavitary fistulae (OR 1.5, 95% CI 0.7 to 3.0). The actuarial 5-year survival rate in surgical survivors was 80% in patients with fistulae and 92% in patients with nonruptured abscesses (log-rank p = 0.6). In conclusion, aortocavitary fistulous tract formation in the setting of native valve IE is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscess. Despite these higher rates of complications, fistulous tract formation in the current era of IE is not an independent risk factor for mortality.

Importance of surgical timing on postoperative outcome in patients with native valve acute endocarditis

BACKGROUND

The present study was undertaken to establish whether surgical outcome could be influenced by surgical timing in patients affected by native valve endocarditis (NVE).

METHODS

From March 2002 to December 2004, 19 patients underwent surgical operation for NVE. Aortic valve replacement (AVR) was performed in ten patients (53%), mitral valve repair (MVRep) was performed in five patients (26%) and multivalvular procedures were performed in the remaining four patients (21%). In three patients (15.5%), emergency surgery was required for refractory congestive heart failure, urgent surgery was necessary in ten patients [in six patients (31%) for paravalvular abscess, in three patients (15.5%) for macrovegetations and in one patient (6%) for systemic embolism, respectively], five patients (26.3%) with isolated valve incompetence underwent elective surgery, whereas delayed surgery was reserved for one patient (6%) because of pre-operative embolic stroke.

RESULTS

There were no surgical procedure, cardiac or infectious related deaths at 30 days in the entire group. One patient died from an intravenous overdose. Follow-up was 100% complete in the 18 hospital survivors and ranged from 4 to 37 months (mean 14.2 +/- 10 months). There were no late death, recurrence of endocarditis, or re-operation at follow-up.

CONCLUSIONS

The surgical results for NVE are excellent if surgical timing criteria are correctly applied during the acute phase of the infectious process. Immediate surgical correction is required when rapid hemodynamic deterioration occurs whereas a more aggressive surgical approach appears to be advisable in the case of paravalvular abscess, macrovegetations or systemic embolism. Delayed surgery is recommended when pre-operative stroke develops.

The role of transthoracic echocardiography in excluding left sided infective endocarditis in Staphylococcus aureus bacteraemia

In all patients with Staphylococcus aureus bacteraemia a transoesophageal echocardiogram is recommended to exclude infective endocarditis. We determined that a finding of normal to trivial valvular regurgitation on transthoracic echocardiogram in these patients significantly reduced the probability of infective endocarditis. Furthermore, in the absence of embolic phenomena the likelihood of infective endocarditis was less than 2%. This probability could be further reduced if the echocardiogram was performed greater than 5 days after the bacteraemia. Therefore, in the assessment of patients with S. aureus bacteraemia a transoesophageal echocardiogram is not always required to exclude infective endocarditis.

Clinical predictors of mortality from infective endocarditis

A cohort study with prospective data collection was conducted to determine which risk factors and outcome variables are statistically significant clinical predictors of mortality from infective endocarditis. A study was performed from an eleven-year, hospitalization cohort (N=11,230) in which the data were collected prospectively. The study examined 21 potential risk factors and 14 outcome variables. The risk factors were categorized into these various groups: patient factors, cardiac factors, co-morbidities, operative factors, infectious factors, and complications. The outcome variables were categorized into operative factors, infectious factors, and complications. Inclusion criteria included patients with endocarditis (N=87). Longer operative time, operative complications, and postoperative complications. Overall mortality was 11.5 percent (N=10). Endocarditis patients who died were significantly older (p=0.023) and had a longer pump time (p=0.017) than those who survived. Endocarditis patients who died were more likely to experience an unstable hemodynamic status (p=0.012). There was a significant difference between survival and non-survival of patients with endocarditis on nine outcome variables. They were more likely to require a re-operation for bleeding (p=0.034). Renal complications (p=0.016), neurological complications (p=0.004), pulmonary complications (p=0.001), intra-operative complications (p=0.035), and IAPB (p<0.001) were all more likely to occur in endocarditis patients who died. There are risk factors that serve as predictors of mortality from infectious endocarditis. These include age greater than 65 years, longer pump time, and unstable hemodynamic status. Outcome variables that reflected significant mortality included operative complications and post-operative complications. These factors may identify those patients with infective endocarditis eligible for more aggressive treatment.

Surgical Management of Infective Endocarditis: Early Predictors of Short-Term Morbidity and Mortality

BACKGROUND

Infective endocarditis is a diagnostic and therapeutic challenge that ultimately requires surgical intervention in 20% of all cases. Early determinants of morbidity and mortality in this high risk population are not well described.

METHODS

The aim of this study was to determine preoperative clinical, microbiological, electrocardiographic, and echocardiographic variables that predicted the need for permanent pacemaker implantation and in-hospital death in a surgical cohort of patients with active infective endocarditis.

RESULTS

We identified 91 patients (61 males and 30 females, mean age 58 +/- 16 years) who underwent surgical intervention for active culture-positive infective endocarditis as defined by the Duke criteria. Native valve infective endocarditis was present in 78 (85.7%) and prosthetic valve endocarditis in 13 (14.3%) of cases. The aortic valve was infected in 61 (67.0%), the mitral in 35 (38.5%), and multiple valves in 8 patients (8.8%). The most common indication for surgical intervention was intractable heart failure. Twenty-two patients (24.2%) required pacemakers, while there were 14 (15.4%) in-hospital deaths. In age-adjusted and gender-adjusted analyses, the presence of left bundle branch block on preoperative electrocardiogram (ECG) and presence of depressed left ventricular systolic function (ejection fraction [EF] < 50%) predicted the need for a permanent pacemaker implantation, while the presence of depressed left ventricular function predicted in-hospital mortality.

CONCLUSIONS

Preoperative ECG findings of left bundle branch block and reduced left ventricular function may allow for early risk stratification of this high risk population.

Complications of native and prosthetic valve infective endocarditis: Update in 2006

Infective endocarditis is a rare disease associated with significant morbidity and mortality. In the past decades, there have been significant improvements in the management of infective endocarditis. Complications are frequent and include heart failure, embolic episodes, periannular complications, and central nervous system events. Surgical therapy has been fundamental in the reduction of mortality in complicated cases. This paper is an overview of the main complications of native and prosthetic infective endocarditis and its treatment.

[Brucella endocardititis: clinical particularities and therapeutic modalities]

Brucella infective endocarditis is an uncommon, but serious complication of brucellosis. The aortic valve is the most commonly affected cardiac valve. Due to characteristics of the infection, medical therapy alone is not sufficient in treating the disease and best results are obtained with surgery combination. We describe a case of Brucella endocarditis involving the aortic valve suspected in front of the clinical data and the results of serology, confirmed by the culture of the native valves. In association with the medical treatment, management valve replacement lead to a favorable medium-term evolution.

Presentation and outcome of infective endocarditis in Spain: a retrospective study

OBJECTIVE

To analyze cases of infective endocarditis in patients who attended the Hospital General de Castellón, Spain, between 1999 and 2004.

METHODS

This was a retrospective study. Demographic and clinical characteristics were assessed, variation in presentation over time was analyzed, and factors influencing outcome were determined.

RESULTS

A total of 54 cases in 48 patients were included; 33 (61%) were in men. The median patient age was 62 years. Infective endocarditis occurred on a native valve in 36 cases (67%), a mechanical prosthetic valve in 12 (22%), and a pacemaker in six (11%). The mitral valve was the most commonly affected site. Transthoracic and/or transesophageal echocardiography showed a vegetation in 45 (83%) cases, moderate or severe valvular regurgitation in 27 (50%), and intracardiac destructive lesions in five (9%). The outcome in 15 (28%) cases was death, and multivariate analysis disclosed significantly increased risk of death associated with older age, lower serum albumin, and higher white blood cell count.

CONCLUSIONS

This study confirmed the protean nature of infective endocarditis, and identified several factors predictive of mortality including advanced age, low serum albumin, and high white blood cell count.

Infective endocarditis: diagnosis and management

Despite advances in antimicrobial therapy, diagnostic imaging and cardiac surgery, infective endocarditis (IE) remains challenging clinically and is associated with high morbidity and mortality. Diagnosis relies on several factors: initial clinical suspicion, microbiological data and echocardiographic findings. The use of an integrated diagnostic schema, such as the modified Duke criteria, is useful. Transthoracic or transesophageal echocardiography should be performed promptly for all suspected IE cases. Although the choice of investigation might be influenced by availability, the approach to imaging should be tailored to the individual's clinical situation. Promptly administered intravenous antimicrobial therapy is essential, while the use of antiplatelet or antithrombin therapy to prevent embolic complications is not supported by clinical data. Deciding whether to undertake cardiac surgery for the treatment of IE can be extremely difficult. The principal indications are the development of heart failure from acute, severe aortic or mitral regurgitation, or perivalvular extension of infection. The timing of surgery following central nervous system embolization is problematic because of the risk of hemorrhagic transformation. Prophylactic surgery to prevent embolization is currently advocated only for the management of large, mobile vegetations, when undertaken at centers performing high volumes of heart valve surgery. In this review, we describe diagnostic approaches for IE, particularly echocardiography, and provide recommendations for treatment, paying particular attention to surgery in the acute setting.

Clinical features and predictors for mortality in patients with infective endocarditis at a university hospital in Taiwan from 1995 to 2003

The clinical features and microbiological characteristics of 315 patients with definite or possible infective endocarditis (IE) from January 1995 to December 2003 were evaluated. There were 187 males and 128 females with a mean age of 51 years (range, 1 month to 92 years). Ninety-three patients (30%) had a diagnosis of valvular heart disease and 24 (8%) had received prosthetic valve replacement. Blood culture was negative in 62 patients (20%). Staphylococci (91 patients, 32%), including methicillin-susceptible Staphylococcus aureus (15%), methicillin-resistant S. aureus (11%), and coagulase-negative staphylococci (6%), were the most commonly encountered pathogens followed by viridans group streptococci (77 patients, 24%). Eight patients (25%) had various neurological, renal, embolic, and cardiac complications. Patients with neurological complications [odds ratio (OR) 8.175, P<0.001], nosocomial IE (OR 6.661, P<0.001), underlying malignancy (OR 4.993, P<0.001), elevated serum creatinine level (OR 3.132, P=0.001), or elevated WBC count (>15000/mm3) (OR 2.537, P=0.007) were at significantly increased risk of mortality. This study found mortality from IE was associated with several factors, among which neurological complications were the most hazardous. Patients with more than one risk factor had poorer prognosis. These results suggest the need for more aggressive management in patients with IE when multiple risk factors for mortality are identified.

Time-related distribution, risk factors and prognostic influence of embolism in patients with left-sided infective endocarditis

BACKGROUND

Few studies evaluated systemic arterial embolism after beginning of symptoms of infective endocarditis in a large series of patients.

METHODS

We studied 629 patients with left-sided infective endocarditis, aged 37.9+/-17.3 years, 396(63%) men and 233(37%) women. Endocarditis occurred on native valves in 405(64.4%) patients and on prosthetic heart valves in 224(35.6%). Infecting microorganisms were streptococci in 297(47.3%) patients, Staphylococcus aureus in 77(12.3%), Staphylococcus epidermidis in 56(8.9%), enterococci in 51(8.1%), Gram-negative bacteria in 33(5.2%), fungi in 9(1.4%) and other microorganisms in 27(4.2%). In 79(12.6%) patients blood cultures were negative.

RESULTS

146 embolic events occurred in 133(21.1%) out of 629 patients; in 63(47.4%) of them emboli affected the central nervous system, in 57(42.9%) affected peripheral organs and in 13(9.7%) affected both the central nervous system and peripheral organs. Embolism occurred between beginning of symptoms of endocarditis and antimicrobial therapy in 56(42.1%) patients and on the day therapy started in 18(13.5%); 109(81.9%) embolic events occurred up to the 15th day of antimicrobial therapy. Embolic risk was higher in S. aureus endocarditis (relative risk 2.97); in patients with a mitral (relative risk 2.4) or aortic (relative risk 3.3) prosthetic valve and vegetations on echocardiography. Embolic risk was lower in patients with a longer duration of symptoms. The death risk doubled in patients with embolism (relative risk 2.01).

CONCLUSIONS

Embolic events were more frequently early events after beginning of symptoms of infective endocarditis. Embolic risk was higher in S. aureus endocarditis and in patients with prosthetic heart valves and vegetations on echocardiography.

Fever of unknown origin, infection of subcutaneous devices, brain abscesses and endocarditis

The term 'fever of unknown origin' includes a wide range of conditions that often remain undiagnosed. The possibility of an infection must be promptly diagnosed in order to begin appropriate therapy. Imaging with radiopharmaceuticals, computed tomography, magnetic resonance imaging and ultrasound are the most commonly applied techniques, usually performed in addition to blood tests, biopsies or tissue cultures when required. The lack of comparative studies investigating the accuracy of each radiopharmaceutical for the study of fever of unknown origin was the incentive to perform a meta-analysis of peer articles published between 1981 and 2004 (33 papers) describing the use of nuclear medicine imaging for this purpose. Furthermore, infection of subcutaneous devices, brain abscesses and endocarditis must be considered amongst the causes of fevers of unknown origin. Reviews of 23, 10 and 10 papers, respectively (from 1976 to 2005), were performed on these specific topics. The results may be a useful guide for the choice of the optimal radiopharmaceutical(s) and diagnostic strategy to be applied in each clinical condition and for different aims.

Changing conduction abnormalities in a dialysis patient with fever

A patient on hemodialysis with severe aortic valve disease and presumed arteriovenous fistula infection was found to have new-onset atrial fibrillation and alternating left and right bundle branch block patterns on serial electrocardiograms. These findings prompted transesophageal echocardiography, which revealed a large abscess involving the intervalvular fibrosa and the posterior cusp of the bicuspid aortic valve. Hence, basic bedside diagnostic skills remain important in the era of sophisticated imaging techniques and laboratory analyses.

Sterile recurrent spinal epidural abscess in a patient with Crohn's disease: a case report

BACKGROUND

The frequency of SEA is increasing. There are several well-established predisposing factors.

CASE DESCRIPTION

Our case presents certain unusual features that include an association with CD, persistent sterile cultures, and multiple recurrences of lesions at adjacent levels.

CONCLUSIONS

A review of the literature showed only 13 case reports of SEA in patients with CD with an additional patient mentioned in one series. Recurrence of SEA at the same location was reported only twice. The diagnostic workup and treatment modalities pertinent to this case are discussed.

Endocarditis after valve replacement surgery. Early recognition and treatment are essential to averting deadly complications

The incidence of infective endocarditis, an inflammation of the heart valves, the endocardium, or both that's caused by bacterial, viral, or fungal agents, continues to rise despite advances in treatment. People with prosthetic valves are among those at highest risk, and mortality rates can be extremely high, especially in cases of early onset. Diagnosis is challenging, in part because signs and symptoms associated with systemic infections can mask signs of the underlying endocarditis. This article outlines the causes and effects of prosthetic valve-related endocarditis (PVE), describes its signs and symptoms, discusses the leading diagnostic tests and criteria, and addresses prevention and treatment, as well as nursing implications.

Real-time 3-Dimensional Echocardiography for Prosthetic Valve Endocarditis: Initial Experience

Real-time 3-dimensional echocardiography is a relatively new technology with rapidly growing potential applications. Prosthetic valve endocarditis is still a challenging diagnosis despite improvements in image qualities obtained by both transthoracic and transesophageal echocardiograms. The purpose of this article is to present 4 cases of suggested prosthetic valve endocarditis, in which real-time 3-dimensional echocardiography was performed, and to discuss the potential use of real-time 3-dimensional echocardiography for this application.

Medical versus surgical management of Staphylococcus aureus prosthetic valve endocarditis

PURPOSE

The study's purpose was to identify prognostic factors associated with mortality in Staphylococcus aureus prosthetic valve endocarditis and to determine whether these factors influenced decisions to treat medically versus surgically. We also analyzed whether there was a subset of patients who were cured with medical therapy alone.

SUBJECTS AND METHODS

A retrospective review of patients with S aureus prosthetic valve endocarditis was performed. Demographic and clinical data were collected from existing medical records. Severity of illness was classified using American Society of Anesthesiologists (ASA) score. Impact of treatment on in-hospital mortality was assessed using multiple logistic regression analysis.

RESULTS

Fifty-five patients met the Duke criteria for definite S aureus prosthetic valve endocarditis. Twenty-three patients were treated medically, and 32 patients had surgical intervention. Overall mortality was 36% (28% in the surgical group and 48% in the medical group). ASA score IV (P < .001) and older age (P = .014) were significant risk factors of mortality. Patients with ASA score IV (P = .037) and multiple prosthetic valves (P = .013) were less likely to undergo surgery. Medically treated patients were older compared with those in the surgical group (median age 66 vs 55 years, P = .04). All 4 patients aged less than 50 years in the medically treated group survived.

CONCLUSION

Mortality was generally higher in the medically treated patients with S aureus prosthetic valve endocarditis. Multivariable analysis showed that ASA class IV and bioprosthetic valves were independent predictors of mortality. A subset of medically treated patients characterized by age less than 50 years, ASA score III, and without cardiac, central nervous system, or systemic complications were cured without surgical intervention.

Epidemiologic, clinical, and microbiologic profile of infective endocarditis in Argentina: a national survey. The Endocarditis Infecciosa en la República Argentina-2 (EIRA-2) Study

BACKGROUND

This study aimed to determine the epidemiologic, clinical, microbiologic characteristics, and inhospital outcome of infective endocarditis (IE) in Argentina and compare the results with those of the 1992 IE national survey.

METHODS

A prospective, multicenter study was conducted in 82 hospitals representing 16 of 24 provinces of Argentina. Patients with diagnosis of IE according to the Duke criteria were surveyed during an 18-month period.

RESULTS

From 470 surveyed episodes of IE, 390 cases were classified as definite and 80 as possible IE. The mean age of the definite IE cases was 58.5 +/- 17.3 years; male sex, 70.0%; and male-female ratio, 2.3:1. Pathological evidence of IE was available in 26.2%. There was no previously known heart disease in 35.1%, and the proportion of prosthetic valve IE was 15.9%. Causative microorganisms were streptococci, 38.3% (Streptococcus viridans 27.0%, Streptococcus bovis 5.2%, others 6.1%); enterococci, 10.2%; staphylococci, 36.7% (Staphylococcus aureus 29.8%, coagulase-negative staphylococci 6.9%); HACEK group, 6.1%; fungal, 1.4%; and polymicrobial, 2.0%. Blood culture results were negative in 10.8%. Surgical treatment was performed in 26.2%, and the overall inhospital mortality was 24.6%. Patients from the 2002 survey were older (58.5 +/- 17.3 vs 51.3 +/- 18.7 years, P < .01) and more frequently had underlying heart disease (64.9% vs 55.0%, P < .01): degenerative valve disease (11.5% vs 4.8%, P < .01), congenital heart disease (9.5% vs 4.2%, P < .01), and prosthetic valve IE (15.9% vs 8.5%, P < .01). Conversely, the prevalence of rheumatic valve disease was significantly less than in the 1992 survey (5.4% vs 13.0%, P < .01).

CONCLUSIONS

The EIRA-2 survey shows that the clinical profile of IE has changed in Argentina. Currently, patients with IE are older and have a higher frequency of underlying heart disease, degenerative valve disease, and prosthetic valve IE than previously. The incidence of staphylococcal IE has increased. Inhospital mortality remains high, suggesting that more aggressive measures are needed for the early identification, prevention, and treatment of IE.

Beta lactam antibiotic monotherapy versus beta lactam-aminoglycoside antibiotic combination therapy for sepsis

BACKGROUND

Optimal antibiotic treatment for sepsis is imperative. Combining a beta-lactam antibiotic with an aminoglycoside antibiotic may have certain advantages over beta-lactam monotherapy.

OBJECTIVES

We compared clinical outcomes for beta lactam-aminoglycoside combination therapy versus beta lactam monotherapy for sepsis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, Issue 3, 2004); MEDLINE (1966 to July 2004); EMBASE (1980 to March 2003); LILACS (1982 to July 2004); and conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (1995 to 2003). We scanned citations of all identified studies and contacted all corresponding authors.

SELECTION CRITERIA

We included randomized and quasi-randomized trials comparing any beta-lactam monotherapy to any combination of one beta-lactam and one aminoglycoside for sepsis.

DATA COLLECTION AND ANALYSIS

The primary outcome was all-cause fatality. Secondary outcomes included treatment failure, superinfections, colonization, and adverse events. Two authors independently collected data. We pooled relative risks (RR) with their 95% confidence intervals (CI) using the fixed effect model. We extracted outcomes by intention-to-treat analysis whenever possible.

MAIN RESULTS

We included 64 trials, randomizing 7586 patients. Twenty trials compared the same beta-lactam in both study arms, while the remaining compared different beta-lactams using a broader spectrum beta-lactam in the monotherapy arm. In studies comparing the same beta-lactam, we observed no difference between study groups with regard to all-cause fatality, RR 1.01 (95% CI 0.75-1.35) and clinical failure, RR 1.11 (95% CI 0.95-1.29). In studies comparing different beta-lactams, we observed an advantage to monotherapy: all cause fatality RR 0.85 (95% CI 0.71-1.01), clinical failure RR 0.77 (95% CI 0.69-0.86). No significant disparities emerged from subgroup and sensitivity analyses, including the assessment of patients with Gram-negative and Pseudomonas aeruginosa infections. We detected no differences in the rate of resistance development. Adverse events rates did not differ significantly between the study groups overall, although nephrotoxicity was significantly more frequent with combination therapy, RR 0.30 (95% CI 0.23-0.39). We found no heterogeneity for all comparisons. We included a small subset of studies addressing patients with Gram-positive infections, mainly endocarditis. We identified no difference between monotherapy and combination therapy in these studies.

AUTHORS' CONCLUSIONS

The addition of an aminoglycoside to beta-lactams for sepsis should be discouraged. All-cause fatality rates are unchanged. Combination treatment carries a significant risk of nephrotoxicity.

Evolving trends in infective endocarditis

Infective endocarditis is a microbial infection of the endocardial surface and, despite improvements in diagnostic accuracy, medical therapy and surgical techniques, mortality remains high. This review focuses on changes in epidemiology, microbiology and diagnosis, as well as changes in medical and surgical management of infective endocarditis affecting native and prosthetic valves in adults, that have evolved during the past two decades. Significant changes have included an increasing involvement of prosthetic valves and nosocomially-acquired disease, an increased involvement of staphylococci as the causative agents, and a recognition that elderly individuals with degenerative valvular disease are the most vulnerable population. Topics still requiring study include whether and when valve replacement should be performed, and how to predict perivalvular complications or embolisation based on echocardiography findings. Optimisation of antimicrobial treatment schemes (choice of the antibiotic, dose and duration) also requires further investigation.

Coronary embolism and subsequent myocardial abscess complicating ventricular aneurysm and tachycardia

A 62-year-old female experienced a ventricular aneurysm and tachycardia caused by coronary embolism from mitral valve endocarditis. The patient underwent endoventricular patch plasty and cryoablation concomitant with valve replacement and survived without any operative complications. Pathological examination suggested that abscess formation played an important role regarding the disruption of the ventricular wall and development of the ventricular aneurysm and tachycardia. In previous reports, a myocardial abscess caused by a septic embolism has only been diagnosed using postmortem examinations as colony growth around the capillary vessels in the myocardium. We considered that our operation was effective and feasible in such an occurrence.