My paper 10 years later: infective endocarditis in the intensive care unit

Critically ill patients with infective endocarditis, neurological complications and indication for cardiac surgery: a multicenter propensity-adjusted study

BACKGROUND

The benefit-risk balance and optimal timing of surgery for severe infective endocarditis (IE) with ischemic or hemorrhagic strokes is unknown. The study aim was to compare the neurological outcome between patients receiving surgery or not.

METHODS

In a prospective register-based multicenter ICU study, patients were included if they met the following criteria: (i) left-sided IE with an indication for heart surgery; (ii) with cerebral complications documented by cerebral imaging before cardiac surgery; (iii) with Sequential Organ Failure Assessment score ≥ 3. Exclusion criteria were isolated right-sided IE, in-hospital acquired IE and patients with cerebral complications only after cardiac surgery. In the primary analysis, the prognostic value of surgery in term of disability at 6 month was assessed by using a propensity score-adjusted logistic regression.

RESULTS

192 patients were included including ischemic stroke (74.5%) and hemorrhagic lesion (15.6%): 67 (35%) had medical treatment and 125 (65%) cardiac surgery. In the propensity score-adjusted logistic regression, a favorable 6-month neurological outcome was associated with surgery (odds ratio 13.8 (95% CI 6.2-33.7). The 1-year mortality was strongly reduced with surgery in the fixed-effect propensity-adjusted Cox model (hazard ratio 0.18; 95% CI 0.11-0.27; p < 0.001). These effects remained whether the patients received delayed surgery (n = 62/125) or not and whether they were deeply comatose (Glasgow Coma Scale ≤ 10) or not.

CONCLUSIONS

In critically ill IE patients with an indication for surgery and previous cerebral events, a better propensity-adjusted neurological outcome was associated with surgery compared with medical treatment.

Endocarditis in critically ill patients: a review

PURPOSE OF REVIEW

To summarize the advances in literature that support the best current practices regarding infective endocarditis (IE) in critically ill patients.

RECENT FINDINGS

IE due to rheumatic diseases has decreased significantly, and in fact, the majority of cases are associated with degenerative valvopathies, prosthetic valves, and cardiovascular implantable electronic devices. The Duke criteria were recently updated, addressing the increasing incidence of new risk factors for IE, such as IE associated with the use of endovascular cardiac implantable electronic devices and transcatheter implant valves. The presence of organ dysfunction, renal replacement therapies, or extracorporeal membrane oxygenation should be considered in the choice of drug and dosage in critically ill patients with suspected or confirmed IE. As highlighted for other severe infections, monitoring of therapeutic antibiotic levels is a promising technique to improve outcomes in critically ill patients with organ dysfunction.

SUMMARY

The diagnostic investigation of IE must consider the current epidemiological criteria and the diagnostic particularities that these circumstances require. A careful evaluation of these issues is necessary for the prompt clinical or surgical management of this infection.

Risk Factors for Mortality in Patients Undergoing Cardiothoracic Surgery for Infective Endocarditis

BACKGROUND

This study aimed to identify risk factors associated with mortality of patients who undergo cardiac surgery for infective endocarditis.

METHODS

A retrospective review was performed of patients with infective endocarditis who underwent cardiac surgery at a quaternary Australian hospital between 2004 and 2014. Patient data were collected and prospectively analyzed.

RESULTS

In all, 465 patients underwent surgery during the study period, with 30 deaths (6.45%). Factors independently associated with in-hospital mortality were increasing age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01 to 1.07; P = .009), active bacterial endocarditis at time of operation (OR 4.91; 95% CI, 1.01 to 23.8; P = .048), preoperative invasive positive pressure ventilation (OR 3.65; 95% CI, 1.18 to 11.27; P = .025), increasing cardiopulmonary bypass time (OR 1.01; 95% CI, 1.006 to 1.014; P < .001), and increasing European System for Cardiac Operative Risk Evaluation score (OR 21.73; 95% CI, 2.12 to 223.11; P < .01).

CONCLUSIONS

The in-hospital mortality of patients with infective endocarditis remains significant, with potential risk factors including increasing age, active bacterial endocarditis, preoperative invasive positive pressure ventilation, increasing cardiopulmonary bypass time, and high European System for Cardiac Operative Risk Evaluation score.

Infective endocarditis in 13 cats

INTRODUCTION

To describe the clinical presentation, clinicopathological abnormalities and outcomes of a series of cats diagnosed with infective endocarditis (IE) at two tertiary care referral institutions.

ANIMALS

Thirteen client-owned cats presenting to the cardiology or emergency services of tertiary referral institutions with a diagnosis of endocarditis based on the modified Duke criteria.

MATERIALS AND METHODS

Retrospective case series. Medical records were reviewed to extract relevant data. In addition, cases that had cardiac tissue available were evaluated by polymerase chain reaction for the presence of Bartonella DNA.

RESULTS

Prevalence of feline IE was 0.007%. Cats with endocarditis tended to be older (median age: 9 years, range: 2-12 years) and no sex or breed was overrepresented. Commonly encountered clinical signs included respiratory distress (n = 5) and locomotor abnormalities of varying severity (n = 5). Echocardiographic examination detected valvular lesions consistent with endocarditis on the aortic (n = 8) or mitral (n = 5) valves. Nine cats were diagnosed with congestive heart failure at the time of endocarditis diagnosis. Overall, prognosis was grave with a median survival time of 31 days.

CONCLUSIONS

In contrast to dogs, cats with IE typically present with clinical signs consistent with cardiac decompensation and locomotor abnormalities suggestive of either thromboembolic disease or inflammatory arthritis. Given the advanced state of disease when diagnosis typically occurs, prognosis is grave.

Advantages and Limitations of Direct PCR Amplification of Bacterial 16S-rDNA from Resected Heart Tissue or Swabs Followed by Direct Sequencing for Diagnosing Infective Endocarditis: A Retrospective Analysis in the Routine Clinical Setting

Infective endocarditis (IE) is a life-threatening disease that is associated with high morbidity and mortality. Its long-term prognosis strongly depends on a timely and optimized antibiotic treatment. Therefore, identification of the causative pathogen is crucial and currently based on blood cultures followed by characterization and susceptibility testing of the isolate. However, antibiotic treatment starting prior to blood sampling or IE caused by fastidious or intracellular microorganisms may cause negative culture results. Here we investigate the additional diagnostic value of broad-range PCR in combination with direct sequencing on resected heart tissue or swabs in patients with tissue or swab culture-negative IE in a routine clinical setting. Sensitivity, specificity, and positive and negative predictive values of broad-range PCR from diagnostic material in our patients were 33.3%, 76.9%, 90.9%, and 14.3%, respectively. We identified a total of 20 patients (21.5%) with tissue or culture-negative IE who profited by the additional application of broad-range PCR. We conclude that broad-range PCR on resected heart tissue or swabs is an important complementary diagnostic approach. It should be seen as an indispensable new tool for both the therapeutic and diagnostic management of culture-negative IE and we thus propose its possible inclusion in Duke's diagnostic classification scheme.