Guidelines in review: Comparison of ESC and AHA guidance for the diagnosis and management of infective endocarditis in adults. Are the differences clinically relevant? The European perspective

Global magnitude and temporal trend of infective endocarditis, 1990-2019: results from the Global Burden of Disease Study

AIMS

To estimate the spatiotemporal patterns in infective endocarditis (IE) burden along with its attributable risk factors at the national, regional, and global levels, which is essential to optimize the targeted prevention, clinical practice, and research.

METHODS AND RESULTS

Based on all available data sources, the incidence, mortality, and disability-adjusted life years (DALYs) of IE in 204 countries and regions from 1990 to 2019 were reconstructed by Global Burden of Disease Study 2019 using the Cause of Death Ensemble model, spatiotemporal Gaussian process regression, and DisMod-MR 2.1. We depicted the epidemiological characteristics of IE in detail by gender, region, and age. Globally, 1 090 527 incident cases, 66 322 deaths, and 1 723 594 DALYs of IE were estimated in 2019. The age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) increased from 9.91 and 0.73 to 13.80 and 0.87 per 100 000 person-years over the past 30 years, respectively. ASIR were consistently more pronounced in higher socio-demographic index (SDI) regions. The leading ASMR in 2019 appeared in the High SDI region, with the largest increase in the past three decades. The age-specific burden rate of IE among people over 25 years old usually increased with age, and the annual increasing trend was more obvious for people over 60 years of age, especially in higher SDI regions.

CONCLUSION

The incidence and mortality of IE have continued to rise in the past 30 years, especially in higher SDI regions. The patient population was gradually shifting from the young to the elderly.

[Aspiration-based endocarditis debridement of a competent tricuspid valve in a high-risk case of tricuspid valve endocarditis secondary to cardiac device-related infective endocarditis]

INTRODUCTION

The incidence of tricuspid valve endocarditis secondary to cardiac device-related infective endocarditis is rising, probably due to an increasing number of implantations. We describe a novel therapy approach using standard cardiology diagnostic catheter guided by periinterventional transesophageal echocardiographic imaging for aspiration-based endocarditis debridement of the tricuspid valve in a high-risk-patient.

HISTORY

A 65-year-old patient presented with right-heart endocarditis associated with cardiac device-related infective endocarditis. He had a history of ischemic cardiomyopathy, 3-vessel coronary artery disease and was successfully resuscitated one year ago with subsequent implantation of an implantable cardioverter-defibrillator (ICD).

FINDINGS AND DIAGNOSIS

Echocardiography revealed typical endocarditis vegetations on the defibrillator lead and the tricuspid valve. Moreover peripheral septic embolism was suspected.

THERAPY AND COURSE

The cardioverter-defibrillator was explanted and extensive antiinfective therapy was established as the patient was in a state of persistent bacteremia and prolonged septic shock. Open heart surgery was dismissed due the patient´s increased risk of mortality. After interdisciplinary consensus an aspiration-based endocarditis debridement of the tricuspid valve with maintained valve-functionality using a standard cardiology was carried out.

CONCLUSION

Aspiration-based endocarditis debridement in right-heart endocarditis in high-risk patients using a standard cardiology diagnostic catheter can be an alternative to open heart surgery. However, larger clinical studies are needed to define the safety and prognostic benefit of an interventional catheter approach in infective endocarditis.

Improvement of diagnostic accuracy of 18fluorine-fluorodeoxyglucose PET/computed tomography in detection of infective endocarditis using a 72-h low carbs protocol

BACKGROUND

The major challenge in diagnosing infective endocarditis using fluorine-fluorodeoxyglucose (F-FDG) PET/computed tomography (CT) is the high physiological myocardial F-FDG uptake, which may interfere with the detection of pathological uptake. Our aim was to retrospectively analyse the impact of a low-carbohydrate, high-protein, high-fat (LCHPHF) diet starting 72 h before the examination with classic overnight fasting.

METHODS

We included 92 patients (51 with LCHPHF diet 72 h before the examination and 41 with overnight fast only). Left ventricular (LV) myocardial F-FDG uptake was visually evaluated, to estimate the effect of LCHPHF on myocardial F-FDG uptake, we used a three-point visual scale: 0, negligible uptake and evaluable examination; 1, mild uptake and doubtful examination and 2, intense uptake and not evaluable examination. SUVmax and SUVmean were calculated putting a region of interest on LV myocardium at the level of the largest cardiac footprint and on the site of suspected lesion. Thus, a ratio between SUV of the suspect lesion and SUV of LV was calculated as SUV ratio.

RESULTS

By visual assessment, in LCHPHF diet group 46 patients (96.1%) had score 0, 3 patients (5.9%) had score 1 and nobody had score 2. In control group, 23 patients (56.1%) had a score 2, 12 (29.3%) patients obtained a score 1 with a doubtful examination and 6 patients (14.6%) were classified with a score 0 with reportable examination.

CONCLUSION

We demonstrated that an LCHPHF diet can adequately suppress the physiological myocardial uptake leading to a significant improvement in the interpretability and diagnostic accuracy of F-FDG PET/CT in infective endocarditis.

A comparison of different antibiotic regimens for the treatment of infective endocarditis

BACKGROUND

Infective endocarditis is a microbial infection of the endocardial surface of the heart. Antibiotics are the cornerstone of treatment, but due to the differences in presentation, populations affected, and the wide variety of micro-organisms that can be responsible, their use is not standardised. This is an update of a review previously published in 2016.

OBJECTIVES

To assess the existing evidence about the clinical benefits and harms of different antibiotics regimens used to treat people with infective endocarditis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase Classic and Embase, LILACS, CINAHL, and the Conference Proceedings Citation Index - Science on 6 January 2020. We also searched three trials registers and handsearched the reference lists of included papers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of antibiotic regimens for treating definitive infective endocarditis diagnosed according to modified Duke's criteria. We considered all-cause mortality, cure rates, and adverse events as the primary outcomes. We excluded people with possible infective endocarditis and pregnant women.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment, and data extraction in duplicate. We constructed 'Summary of findings' tables and used GRADE methodology to assess the quality of the evidence. We described the included studies narratively.

MAIN RESULTS

Six small RCTs involving 1143 allocated/632 analysed participants met the inclusion criteria of this first update. The included trials had a high risk of bias. Three trials were sponsored by drug companies. Due to heterogeneity in outcome definitions and different antibiotics used data could not be pooled. The included trials compared miscellaneous antibiotic schedules having uncertain effects for all of the prespecified outcomes in this review. Evidence was either low or very low quality due to high risk of bias and very low number of events and small sample size. The results for all-cause mortality were as follows: one trial compared quinolone (levofloxacin) plus standard treatment (antistaphylococcal penicillin (cloxacillin or dicloxacillin), aminoglycoside (tobramycin or netilmicin), and rifampicin) versus standard treatment alone and reported 8/31 (26%) with levofloxacin plus standard treatment versus 9/39 (23%) with standard treatment alone; risk ratio (RR) 1.12, 95% confidence interval (CI) 0.49 to 2.56. One trial compared fosfomycin plus imipenem 3/4 (75%) versus vancomycin 0/4 (0%) (RR 7.00, 95% CI 0.47 to 103.27), and one trial compared partial oral treatment 7/201 (3.5%) versus conventional intravenous treatment 13/199 (6.53%) (RR 0.53, 95% CI 0.22 to 1.31). The results for rates of cure with or without surgery were as follows: one trial compared daptomycin versus low-dose gentamicin plus an antistaphylococcal penicillin (nafcillin, oxacillin, or flucloxacillin) or vancomycin and reported 9/28 (32.1%) with daptomycin versus 9/25 (36%) with low-dose gentamicin plus antistaphylococcal penicillin or vancomycin; RR 0.89, 95% CI 0.42 to 1.89. One trial compared glycopeptide (vancomycin or teicoplanin) plus gentamicin with cloxacillin plus gentamicin (13/23 (56%) versus 11/11 (100%); RR 0.59, 95% CI 0.40 to 0.85). One trial compared ceftriaxone plus gentamicin versus ceftriaxone alone (15/34 (44%) versus 21/33 (64%); RR 0.69, 95% CI 0.44 to 1.10), and one trial compared fosfomycin plus imipenem versus vancomycin (1/4 (25%) versus 2/4 (50%); RR 0.50, 95% CI 0.07 to 3.55). The included trials reported adverse events, the need for cardiac surgical interventions, and rates of uncontrolled infection, congestive heart failure, relapse of endocarditis, and septic emboli, and found no conclusive differences between groups (very low-quality evidence). No trials assessed quality of life.

AUTHORS' CONCLUSIONS

This first update confirms the findings of the original version of the review. Limited and low to very low-quality evidence suggests that the comparative effects of different antibiotic regimens in terms of cure rates or other relevant clinical outcomes are uncertain. The conclusions of this updated Cochrane Review were based on few RCTs with a high risk of bias. Accordingly, current evidence does not support or reject any regimen of antibiotic therapy for the treatment of infective endocarditis.