Infective endocarditis

Bacteriophage therapy and infective endocarditis - is it realistic?

Infective endocarditis (IE) is a severe infection of the inner heart. Even with current standard treatment, the mean in-hospital mortality is as high as 15-20%, and 1-year mortality is up to 40% for left-sided IE. Importantly, IE mortality rates have not changed substantially over the past 30 years, and the incidence of IE is rising. The treatment is challenging due to the bacterial biofilm mode of growth inside the heart valve vegetations, resulting in antibiotic tolerance. Achieving sufficient antibiotic anti-biofilm concentrations in the biofilms of the heart valve vegetations is problematic, even with high-dose and long-term antibiotic therapy. The increasing prevalence of IE caused by antibiotic-resistant bacteria adds to the challenge. Therefore, adjunctive antibiotic-potentiating drug candidates and strategies are increasingly being investigated. Bacteriophage therapy is a reemerging antibacterial treatment strategy for difficult-to-treat infections, mainly biofilm-associated and caused by multidrug-resistant bacteria. However, significant knowledge gaps regarding the safety and efficacy of phage therapy impede more widespread implementation in clinical practice. Hopefully, future preclinical and clinical testing will reveal whether it is a viable treatment. The objective of the present review is to assess whether bacteriophage therapy is a realistic treatment for IE.

Self-assessed health status and associated mortality in endocarditis: secondary findings from the POET trial

PURPOSE

Self-assessed poor health status is associated with increased risk of mortality in several cardiovascular conditions, but has not been investigated in patients with endocarditis. We examined health status and mortality in patients with endocarditis.

METHODS

This is a re-specified substudy of the randomized POET endocarditis trial, which included 400 patients. Patients completed the single-question self-assessed health status from the Short-Form 36 questionnaire at time of randomization and were categorized as having poor or non-poor (excellent/very good, good, or fair) health status. Self-assessed health status and all-cause mortality were examined by a Cox regression model.

RESULTS

Self-assessed health status was completed by 266 (67%) patients with a mean age of 68.0 years (± 11.8), 54 (20%) were females, and 86 (32%) had one or more major concurrent medical conditions besides endocarditis. The self-assessed health status distribution was poor (n = 21, 8%) and non-poor (n = 245, 92%). The median follow-up was 3.3 years and death occurred in 9 (43%) and 48 (20%) patients reporting poor and non-poor health status, respectively, and mortality rates [mortality/100 person-years, 95% confidence interval (CI)] were 18.1 (95% CI 9.4-34.8) and 5.4 (95% CI 4.1-7.2), i.e., the crude hazard ratio for death was 3.4 (95% CI: 1.7-7.0, p < 0.01).

CONCLUSION

Self-assessed poor health status compared with non-poor health status as assessed by a single question was associated with a threefold increased long-term mortality in patients with endocarditis. POET ClinicalTrials.gov number, NCT01375257.

TRIAL REGISTRY

POET ClinicalTrials.gov number, NCT01375257.

Biventricular Native Valve Endocarditis in a Patient with No Cardiac Disease and Predisposing Factor - Case Report

Background: Infective endocarditis is a challenging clinical situation that causes numerous complications. Multi-valvular endocarditis, which is seen less frequently than single valvular endocarditis, is often a fatal disease. In this article, we present a case of endocarditis with native mitral and tricuspid valve involvement in a patient without any underlying predisposing factors. Case report:A 62-year-old patient was admitted to hospital with shortness of breath without any underlying predisposing factors. Covid-19 PCR swab was negative. Transthoracic echocardiography revealed bi-sided valve endocarditis with mitral and tricuspid valve involvement. The patient was taken to the intensive care unit. Transthoracic and transesophageal echocardiography revealed valvular involvement, flail mitrale with severe regurgitation on both valvules. The patient and patient's relatives refused the valvular operation because of the higher risk. Despite the antibiotic treatment, the general condition of the patient deteriorated and died. Conclusion:Multi-valvular endocarditis is a serious disorder with high mortality. In diagnosis, imaging procedures should be utilized as early as possible. Staphylococci are the most common pathogens in such cases, in which early diagnosis and treatment, particularly using a surgical approach, are appropriate.

Endocarditis at a large community hospital with on-site cardiac surgery

Objective

Infective endocarditis (IE) is still a serious disease. The currently published EURO-ENDO registry showed a rate of surgery of 51.2% and a lower mortality in operated IE patients. We hypothesized differences between our data and the registry.

Methods

Retrospective single centre registry on the hospital course of patients with IE.

Results

In four years, 171 IE patients were treated at our hospital. Mean age of patients was 66.5 ± 13.8 years and 62.6% of patients were transferred from other hospitals. There were 85 (49.7%) patients with native valve IE (NVE), 53 (31%) with prosthetic valve IE (PVE) and 33 (19.3%) with either intra-cardiac device related IE (n = 29) or IE associated with central access lines (n = 4) (DRE). A total of 81.3% (n = 139) of patients were sent to cardiac surgery. Using a logistic regression model to analyse predictors of conservative instead of surgical therapy the only independent variables were: presence of large vegetation or abscesses (OR: 0.36, 95%CI 0.15-0.83; p = 0.016) and age (for each ten years) (OR: 1.61, 95%CI 1.11-2.32, p = 0.01). Hospital mortality was 21.6% (n = 37/171), with no difference (p = 0.97) between those who were operated (21.6%, n = 30/139) and those treated conservatively (21.9%, n = 7/32). Comparing those treated conservatively without an indication for surgery with those with an indication, mortality was 9.5% versus 45.5%, p = 0.02.

Conclusions

In this registry from a hospital with on-site cardiac surgery more than half of patients were referred. The rate of patients treated surgically was 81.3%. Hospital mortality was 21.6%, with no difference between operated and conservatively treated patients.

Learning From Controversy: Contemporary Surgical Management of Aortic Valve Endocarditis

Aortic valve replacement is the commonest cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies guided by the comprehensive evaluation of the extension of the infection and its microbiological characteristics, clinical profile of the patient, and risk of infection recurrence are currently available. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. However, in cases of complex IE with the involvement of the root or the aortomitral continuity, the use of homograft is suggested according to the surgeon and center experience. Homograft use should be counterbalanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit (mechanical and bioprosthetic) are also potentially suitable alternatives. Further development of preservation techniques enabling longer durability of allogenic substitutes is required. We evaluate the current evidence for the use of valve substitutes in aortic valve endocarditis and propose an evidence-based algorithm to guide the choice of therapy. We performed a systemic review to clarify the contemporary surgical management of aortic valve endocarditis.

Prosthetic mitral valve Aspergillus fumigatus endocarditis

Aspergillus endocarditis is a fatal source of valvular infection with a near 100 % mortality rate if pharmacotherapy and valve-replacement surgery are not initiated swiftly after diagnosis. Complicating its diagnosis is the low yield for growth on standard blood culture and time requirements for molecular diagnostic tools to return a result. Aspergillus endocarditis of the mitral valve presents as valvular vegetations that reduce the caliber of the mitral valve and can cause syncope as in the case of mitral stenosis with subsequent valve failure, left atrial enlargement, and prospective cardiovascular failure. Reports of the management of Aspergillus endocarditis after serial mitral valve replacement are not prominent in the literature. We report the case of a 41-year-old female with previous mitral valve prosthesis who received a second prosthetic mitral valve after a syncopal episode. Vegetations resembling thrombi were noted on transesophageal echocardiogram, diagnosed as Aspergillus fumigatus endocarditis, and successfully treated with antifungal therapy in conjunction with removal of her dysfunctional prosthesis.

Quantifying infective endocarditis risk in patients with predisposing cardiac conditions

Aims

There are scant comparative data quantifying the risk of infective endocarditis (IE) and associated mortality in individuals with predisposing cardiac conditions.

Methods and results

English hospital admissions for conditions associated with increased IE risk were followed for 5 years to quantify subsequent IE admissions. The 5-year risk of IE or dying during an IE admission was calculated for each condition and compared with the entire English population as a control. Infective endocarditis incidence in the English population was 36.2/million/year. In comparison, patients with a previous history of IE had the highest risk of recurrence or dying during an IE admission [odds ratio (OR) 266 and 215, respectively]. These risks were also high in patients with prosthetic valves (OR 70 and 62) and previous valve repair (OR 77 and 60). Patients with congenital valve anomalies (currently considered ‘moderate risk’) had similar levels of risk (OR 66 and 57) and risks in other ‘moderate-risk’ conditions were not much lower. Congenital heart conditions (CHCs) repaired with prosthetic material (currently considered ‘high risk’ for 6 months following surgery) had lower risk than all ‘moderate-risk’ conditions—even in the first 6 months. Infective endocarditis risk was also significant in patients with cardiovascular implantable electronic devices.

Conclusion

These data confirm the high IE risk of patients with a history of previous IE, valve replacement, or repair. However, IE risk in some ‘moderate-risk’ patients was similar to that of several ‘high-risk’ conditions and higher than repaired CHC. Guidelines for the risk stratification of conditions predisposing to IE may require re-evaluation.

Clinical Analysis of 161 Cases of Surgical Treatment of Infective Endocarditis

Objective: To evaluate the diagnostic criteria, surgical indications, and prognostic factors in the surgical treatment of infective endocarditis (IE). Methods: A total of 161 cases of post-operative IE treated at our hospital from January 2007 to December 2016 were included. The IE was diagnosed by the modified Duke criteria. Echocardiography and standard blood cultures were performed. These cases were divided into severe and non-severe adverse event groups. The association between prognostic factors and severe versus non-severe outcomes was examined using logistic regression. Results: Thirty patients (20.1%) with post-operative IE had positive pre-operative blood cultures, and 130 patients (80.7%) had valve vegetations. Four patients (2.5%) died within 30 days post-operatively. Twenty-two patients experienced severe adverse events. There were significant differences between the two groups regarding their serum albumin and creatinine concentrations, ejection fraction, and hospitalization, cardiopulmonary bypass, aortic cross-clamp, intensive care unit (ICU), and ventilation times (all p < 0.05). The bypass time, aortic cross-clamp time, and ICU time were identified as prognostic factors for severe adverse events. Conclusion: Echocardiography is an important diagnostic method for IE, and repeated tests might improve the sensitivity of diagnosis. Cardiac surgery seems to be an effective treatment for IE. Patient screening and reducing the operative time may improve the prognosis for patients who undergo surgical treatment for IE.

The Many Faces of Bacterium-Endothelium Interactions during Systemic Infections

A wide variety of pathogens reach the circulatory system during viral, parasitic, fungal, and bacterial infections, causing clinically diverse pathologies. Such systemic infections are usually severe and frequently life-threatening despite intensive care, in particular during the age of antibiotic resistance. Because of its position at the interface between the blood and the rest of the organism, the endothelium plays a central role during these infections. Using several examples of systemic infections, we explore the diversity of interactions between pathogens and the endothelium. These examples reveal that bacterial pathogens target specific vascular beds and affect most aspects of endothelial cell biology, ranging from cellular junction stability to endothelial cell proliferation and inflammation.

Clinical risk factors for acute ischaemic and haemorrhagic stroke in patients with infective endocarditis

BACKGROUND

Stroke as a complication of infective endocarditis portends a poor prognosis, yet risk factors for stroke subtypes have not been well defined.

AIM

To identify risk factors associated with ischaemic and haemorrhagic strokes.

METHODS

A retrospective patient chart review was performed at a single US academic centre to identify risk factors and imaging for patients who were 18 years or older with infectious endocarditis (IE) and stroke diagnoses. Differences in patient characteristics by stroke status were assessed using univariate analysis, χ² or student's t-test as well as logistic regression models for multivariable analyses and correlation matrices to identify possible collinearity between variables and to obtain odds ratios (OR) and their 95% confidence intervals.

RESULTS

A final sample of 1157 participants was used for this analysis. The total number of non-surgical strokes was 178, with a prevalence of 15.4% (78% ischaemic, 10% parenchymal haemorrhages, 8% subarachnoid haemorrhages and 4% mixed ischaemic/haemorrhagic). Multivariate risk factors for ischaemic stroke included prior stroke (OR 2.0, 1.3-3.1), Staphylococcus infection (OR 2.0, 1.3-3.0), mitral vegetations (OR 2.2, 1.4-3.3) and valvular abscess (OR 2.7, 1.7-4.3). Risk factors for haemorrhagic stroke included fungal infection (OR 6.4, 1.2-34.0), male gender (OR 3.5, 1.4-8.3) and rheumatic heart disease (OR 3.3, 1.1-10.4).

CONCLUSION

Among patients with IE, there exist characteristics that relate differentially to ischaemic and haemorrhagic stroke risk.

Genetics of sanguinis-Group Streptococci in Health and Disease

With the application of increasingly advanced "omics" technologies to the study of our resident oral microbiota, the presence of a defined, health-associated microbial community has been recognized. Within this community, sanguinis-group streptococci, comprising the closely related Streptococcus sanguinis and Streptococcus gordonii, together with Streptococcus parasanguinis, often predominate. Their ubiquitous and abundant nature reflects the evolution of these bacteria as highly effective colonizers of the oral cavity. Through interactions with host tissues and other microbes, and the capacity to readily adapt to prevailing environmental conditions, sanguinis-group streptococci are able to shape accretion of the oral plaque biofilm and promote development of a microbial community that exists in harmony with its host. Nonetheless, upon gaining access to the blood stream, those very same colonization capabilities can confer upon sanguinis-group streptococci the ability to promote systemic disease. This article focuses on the role of sanguinis-group streptococci as the commensurate commensals, highlighting those aspects of their biology that enable the coordination of health-associated biofilm development. This includes the molecular mechanisms, both synergistic and antagonistic, that underpin adhesion to substrata, intercellular communication, and polymicrobial community formation. As our knowledge of these processes advances, so will the opportunities to exploit this understanding for future development of novel strategies to control oral and extraoral disease.

Identification of pathogens in culture-negative infective endocarditis cases by metagenomic analysis

BACKGROUND

Pathogens identification is critical for the proper diagnosis and precise treatment of infective endocarditis (IE). Although blood and valve cultures are the gold standard for IE pathogens detection, many cases are culture-negative, especially in patients who had received long-term antibiotic treatment, and precise diagnosis has therefore become a major challenge in the clinic. Metagenomic sequencing can provide both information on the pathogenic strain and the antibiotic susceptibility profile of patient samples without culturing, offering a powerful method to deal with culture-negative cases.

METHODS

To assess the feasibility of a metagenomic approach to detect the causative pathogens in resected valves from IE patients, we employed both next-generation sequencing and Oxford Nanopore Technologies MinION nanopore sequencing for pathogens and antimicrobial resistance detection in seven culture-negative IE patients. Using our in-house developed bioinformatics pipeline, we analyzed the sequencing results generated from both platforms for the direct identification of pathogens from the resected valves of seven clinically culture-negative IE patients according to the modified Duke criteria.

RESULTS

Our results showed both metagenomics methods can be applied for the causative pathogen detection in all IE samples. Moreover, we were able to simultaneously characterize respective antimicrobial resistance features.

CONCLUSION

Metagenomic methods for IE detection can provide clinicians with valuable information to diagnose and treat IE patients after valve replacement surgery. However, more efforts should be made to optimize protocols for sample processing, sequencing and bioinformatics analysis.

The impact of hemodialysis on mortality risk and cause of death in Staphylococcus aureus endocarditis

Background

The risk of infective endocarditis (IE) is markedly increased in patients receiving chronic hemodialysis compared with the general population, but outcome data are sparse. The present study investigated causes and risk factors of mortality in a hemodialysis-treated end-stage kidney disease- (ESKD) and a non-ESKD population with staphylococcus (S.) aureus endocarditis.

Methods

Hemodialysis-treated ESKD patients with S. aureus endocarditis were identified from Danish National Registries and Non-ESKD patients from The East Danish Database on Endocarditis. For establishing the cause of death The Danish Registry of Cause of Death was used. Independent risk factors of outcome were identified in multivariable Cox regression models.

Results

One hundred twenty-one hemodialysis patients and 190 non-ESKD patients with S. aureus endocarditis were included during 1996–2012 and 2002–2012, respectively. The all-cause in-hospital mortality was 22.3% in hemodialysis- and 24.7% in non-ESKD patients. One-year mortality, excluding in-hospital mortality, was 26.4% in hemodialysis patients and 15.2% in non-ESKD patients.

The hazard ratio of all-cause mortality in hemodialysis was 2.64 (95% CI 1.70–4.10) at > 70 days after admission compared with non-ESKD. Age (HR 1.03 (95% CI 1.02–1.04)) and diabetes mellitus (HR 2.17 (95% CI 1.54–3.10)) were independent risk factors of all-cause mortality. The hazard ratio of cardiovascular death in hemodialysis was 3.20 (95% CI 1.78–5.77) at > 81 days after admission compared with non-ESKD. Age and diabetes mellitus were independently related to cardiovascular death.

Conclusion

All-cause in-hospital mortality rates were similar in hemodialysis and non-ESKD patients with S. aureus endocarditis whereas one-year mortality rates were significantly increased in the hemodialysis population.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1016-0) contains supplementary material, which is available to authorized users.

Workup and Management of Native and Prosthetic Valve Endocarditis

Infective endocarditis (IE) is associated with significant serious adverse outcomes including death. IE usually presents with diverse clinical picture and syndromic diagnoses including heart failure, stroke, and peripheral embolization. Given variable, vague, and syndromic presentations, the diagnosis of IE may be delayed for days to weeks. Maintaining a high index of suspicion among clinicians is the key to early recognition of the disease and prompt initiation of antimicrobial therapy to prevent IE-associated mortality and morbidity. Blood culture and echocardiography remain essential tools in the diagnosis of infective endocarditis. However, advances in molecular techniques, serology testing, computed tomography scan, and nuclear medicine have led to growth in the available tools that may aid in early diagnosis of infective endocarditis. Antimicrobial agents are the mainstay of IE therapy; however, as many as 50% of endocarditis cases will undergo valve surgery, even on an urgent or emergent basis.

Functional limitations and educational needs among children and adolescents with heart disease

OBJECTIVE

To examine how cognitive and motor limitations in children with heart disease are associated with education and participation in extracurricular activities.

DESIGN

Using 2009-2010 parent-reported data from the National Survey of Children with Special Health Care Needs (NS-CSHCN), we examined prevalence of five functional limitations (learning/concentration, communication, self-care, gross motor skills, and fine motor skills) by diagnosed heart disease status using chi-square tests and multivariable logistic regression. Among CSHCN with heart disease, we examined the associations between severity of each functional limitation and missing ≥11 days of school in the past year, receiving special education services, and interference with extracurricular activities.

RESULTS

CSHCN with heart disease (n = 1,416), compared to CSHCN without (n = 28,385), more commonly had "a lot" of difficulty in the five functional areas (P < .01; adjusted odds ratios: 1.8-3.3). Among CSHCN with heart disease, "a lot" of difficulty with learning/concentration was most common (35%), followed by communication (21%), self-care (14%), gross motor skills (12%), and fine motor skills (10%). Among CSHCN with heart disease, compared to those without, respectively, 27% and 15% missed ≥11 days of school, 45% and 29% received special education services, and 49% and 29% experienced interference with extracurricular activities (P < .01 for all). Level of difficulty with the five functional areas was associated with receipt of special education services and participation in extracurricular activities (P < .001).

CONCLUSION

These results support the American Heart Association recommendations to screen children with congenital heart disease for age-appropriate development and provide services when needed.

The Road to Infection: Host-Microbe Interactions Defining the Pathogenicity of Streptococcus bovis/Streptococcus equinus Complex Members

The Streptococcus bovis/Streptococcus equinus complex (SBSEC) comprises several species inhabiting the animal and human gastrointestinal tract (GIT). They match the pathobiont description, are potential zoonotic agents and technological organisms in fermented foods. SBSEC members are associated with multiple diseases in humans and animals including ruminal acidosis, infective endocarditis (IE) and colorectal cancer (CRC). Therefore, this review aims to re-evaluate adhesion and colonization abilities of SBSEC members of animal, human and food origin paired with genomic and functional host-microbe interaction data on their road from colonization to infection. SBSEC seem to be a marginal population during GIT symbiosis that can proliferate as opportunistic pathogens. Risk factors for human colonization are considered living in rural areas and animal-feces contact. Niche adaptation plays a pivotal role where Streptococcus gallolyticus subsp. gallolyticus (SGG) retained the ability to proliferate in various environments. Other SBSEC members have undergone genome reduction and niche-specific gene gain to yield important commensal, pathobiont and technological species. Selective colonization of CRC tissue is suggested for SGG, possibly related to increased adhesion to cancerous cell types featuring enhanced collagen IV accessibility. SGG can colonize, proliferate and may shape the tumor microenvironment to their benefit by tumor promotion upon initial neoplasia development. Bacteria cell surface structures including lipotheichoic acids, capsular polysaccharides and pilus loci (pil1, pil2, and pil3) govern adhesion. Only human blood-derived SGG contain complete pilus loci and other disease-associated surface proteins. Rumen or feces-derived SGG and other SBSEC members lack or harbor mutated pili. Pili also contribute to binding to fibrinogen upon invasion and translocation of cells from the GIT into the blood system, subsequent immune evasion, human contact system activation and collagen-I-binding on damaged heart valves. Only SGG carrying complete pilus loci seem to have highest IE potential in humans with significant links between SGG bacteremia/IE and underlying diseases including CRC. Other SBSEC host-microbe combinations might rely on currently unknown mechanisms. Comparative genome data of blood, commensal and food isolates are limited but required to elucidate the role of pili and other virulence factors, understand pathogenicity mechanisms, host specificity and estimate health risks for animals, humans and food alike.

Mortality Predictors in the Surgical Treatment of Active Infective Endocarditis

INTRODUCTION

Active infective endocarditis is associated with high morbidity and mortality. Surgery is indicated in high-risk conditions, and the main determinants of mortality in surgical treatment should be evaluated.

OBJECTIVE

To identify mortality predictors in the surgical treatment of active infective endocarditis in a long-term follow-up.

METHODS

This prospective observational study involved 88 consecutive patients diagnosed with active infective endocarditis, who underwent surgery between January 2005 and December 2015. Fifty-eight (65.9%) patients were male, the mean age was 50.87±16.15 years. A total of 31 (35.2%) patients had a history of rheumatic fever; 48 (54.5%) had had heart surgery with prosthetic valve implantation; 45 (93.8%) had biological prosthetic valve endocarditis and 3 (6.3%) mechanical prosthetic valve; 40 (45.5%) patients had the disease in their native valve. The mean EuroSCORE II was 8.9±6.5%, and the main surgical indication was refractory heart failure in 38 (43.2%) patients. A total of 68 bioprosthesis (36 aortic, 32 mitral) and 29 mechanical prostheses (12 aortic, 17 mitral) were implanted and three mitral valve plasties performed. A total of 25 (28.4%) patients underwent double or triple valve procedures. Aortic annulus reconstruction by abscess was performed in 18 (20.5%) and six (6.81%) patients had combined procedure. The mean surgery time was 359±97.6 minutes.

RESULTS

The overall survival in up to a 10-year follow-up period was 79.5%. In the univariate analysis, the main mortality predictors were positive blood cultures (P=0.003), presence of typical microorganisms (P=0.008), most frequently Streptococcus viridans (12 cases; 25%); C-reactive protein (hazard ratio [HR] 1.034, 95% confidence interval [CI] 1.000 to 1.070, P=0.04); creatinine clearance (HR 0.977, 95% CI 0.962 to 0.993, P=0.005); length of surgery: every five minutes multiplies the chance of death 1.005-fold (HR 1.005, 95% CI 1.001 to 1.009, P=0.0307); age (HR 1.060, 95% CI 1.026 to 1.096, P=0.001); and EuroSCORE II (HR 1.089, 95% CI 1.030 to 1.151, P=0.003).

CONCLUSION

A positive blood culture with typical microorganism, C-reactive protein, age, EuroSCORE II, total surgical time and the presence of postoperative complications were the major predictors of mortality and significantly impacted survival in up to a 10-year follow-up period.

Short- and long-term outcomes in infective endocarditis patients: a systematic review and meta-analysis

Background

Despite advances in medical knowledge, technology and antimicrobial therapy, infective endocarditis (IE) is still associated with devastating outcomes. No reviews have yet assessed the outcomes of IE patients undergoing short- and long-term outcome evaluation, such as all-cause mortality and IE-related complications. We conducted a systematic review and meta-analysis to examine the short- and long-term mortality, as well as IE-related complications in patients with definite IE.

Methods

A computerized systematic literature search was carried out in PubMed, Scopus and Google Scholar from 2000 to August, 2016. Included studies were published studies in English that assessed short-and long-term mortality for adult IE patients. Pooled estimations with 95% confidence interval (CI) were calculated with DerSimonian-Laird (DL) random-effects model. Sensitivity and subgroup analyses were also performed. Publication bias was evaluated using inspection of funnel plots and statistical tests.

Results

Twenty five observational studies (retrospective, 14; prospective, 11) including 22,382 patients were identified. The overall pooled mortality estimates for IE patients who underwent short- and long-term follow-up were 20% (95% CI: 18.0–23.0, P < 0.01) and 37% (95% CI: 27.0–48.0, P < 0.01), respectively. The pooled prevalence of cardiac complications in patients with IE was found to be 39% (95%CI: 32.0–46.0) while septic embolism and renal complications accounted for 25% (95% CI: 20.0–31) and 19% (95% CI: 14.0–25.0) (all P < 0.01), respectively.

Conclusion

Irrespective of the follow-up period, a significantly higher mortality rate was reported in IE patients, and the burden of IE-related complications were immense. Further research is needed to assess the determinants of overall mortality in IE patients, as well as well-designed observational studies to conform our results.

Electronic supplementary material

The online version of this article (10.1186/s12872-017-0729-5) contains supplementary material, which is available to authorized users.

First case report of endocarditis caused by haematobacter massiliensis in China

BACKGROUND

Haematobacter massiliensis, a rare species of fastidious Gram-negative, non-motile, non-sporing, non-fermentative, pleomorphic, aerobic bacilli, has rarely been documented as the cause of infectious endocarditis in literature. Here we report the first case of infectious endocarditis (IE) caused by H. massiliensis in China.

CASE PRESENTATION

A 44-year-old woman presented to the infectious department of Peking Union Medical College Hospital (Beijing) in August 2013, with a 7-week history of fevers, chills, sore throat, muscular soreness, occasional joint pain, and cough. The organism obtained by blood culture, identified as H. massiliensis by 16S rRNA gene sequencing, was finally implicated as the cause of infectious endocarditis. The patient was cured with amoxicillin/clavulanate combined with amikacin for 6 weeks.

CONCLUSION

This is the first case report in China, of the isolation of H. massiliensis from the bloodstream of a patient with endocarditis. The microbiology and clinical study of the organism will help us understand it better in future clinical practice.

Dental procedures, antibiotic prophylaxis, and endocarditis among people with prosthetic heart valves: nationwide population based cohort and a case crossover study

Objective To assess the relation between invasive dental procedures and infective endocarditis associated with oral streptococci among people with prosthetic heart valves.Design Nationwide population based cohort and a case crossover study.Setting French national health insurance administrative data linked with the national hospital discharge database.Participants All adults aged more than 18 years, living in France, with medical procedure codes for positioning or replacement of prosthetic heart valves between July 2008 and July 2014.Main outcome measures Oral streptococcal infective endocarditis was identified using primary discharge diagnosis codes. In the cohort study, Poisson regression models were performed to estimate the rate of oral streptococcal infective endocarditis during the three month period after invasive dental procedures compared with non-exposure periods. In the case crossover study, conditional logistic regression models calculated the odds ratio and 95% confidence intervals comparing exposure to invasive dental procedures during the three month period preceding oral streptococcal infective endocarditis (case period) with three earlier control periods.Results The cohort included 138 876 adults with prosthetic heart valves (285 034 person years); 69 303 (49.9%) underwent at least one dental procedure. Among the 396 615 dental procedures performed, 103 463 (26.0%) were invasive and therefore presented an indication for antibiotic prophylaxis, which was performed in 52 280 (50.1%). With a median follow-up of 1.7 years, 267 people developed infective endocarditis associated with oral streptococci (incidence rate 93.7 per 100 000 person years, 95% confidence interval 82.4 to 104.9). Compared with non-exposure periods, no statistically significant increased rate of oral streptococcal infective endocarditis was observed during the three months after an invasive dental procedure (relative rate 1.25, 95% confidence interval 0.82 to 1.82; P=0.26) and after an invasive dental procedure without antibiotic prophylaxis (1.57, 0.90 to 2.53; P=0.08). In the case crossover analysis, exposure to invasive dental procedures was more frequent during case periods than during matched control periods (5.1% v 3.2%; odds ratio 1.66, 95% confidence interval 1.05 to 2.63; P=0.03).Conclusion Invasive dental procedures may contribute to the development of infective endocarditis in adults with prosthetic heart valves.

A complication of meningitis and infective endocarditis due to Streptococcus pyogenes

We described a rare case of meningitis and infective endocarditis (IE) due to Streptococcus pyogenes. An 80-year-old woman was admitted to our hospital with unconsciousness. Glasgow Coma Scale was E1V3M5. We diagnosed her with acute meningitis due to S. pyogenes and started treatment using ceftriaxone. In spite of the improvement of her unconscious state, she developed a new-onset systolic murmur on day 13, and echocardiography revealed severe mitral valve regurgitation with vegetation. Therefore, we also diagnosed her with IE and continued the antibiotics for 6 weeks after we confirmed the negative blood cultures. The patient was finally transferred to another hospital for rehabilitation 57 days after admission. Considering that the number of S. pyogenes infections has been reported to increase in Japan and worldwide, we need to be more careful about the rare complication of meningitis and IE due to S. pyogenes.

The Cost-Effectiveness of Antibiotic Prophylaxis for Patients at Risk of Infective Endocarditis

BACKGROUND

In March 2008, the National Institute for Health and Care Excellence recommended stopping antibiotic prophylaxis (AP) for those at risk of infective endocarditis (IE) undergoing dental procedures in the United Kingdom, citing a lack of evidence of efficacy and cost-effectiveness. We have performed a new economic evaluation of AP on the basis of contemporary estimates of efficacy, adverse events, and resource implications.

METHODS

A decision analytic cost-effectiveness model was used. Health service costs and benefits (measured as quality-adjusted life-years) were estimated. Rates of IE before and after the National Institute for Health and Care Excellence guidance were available to estimate prophylactic efficacy. AP adverse event rates were derived from recent UK data, and resource implications were based on English Hospital Episode Statistics.

RESULTS

AP was less costly and more effective than no AP for all patients at risk of IE. The results are sensitive to AP efficacy, but efficacy would have to be substantially lower for AP not to be cost-effective. AP was even more cost-effective in patients at high risk of IE. Only a marginal reduction in annual IE rates (1.44 cases in high-risk and 33 cases in all at-risk patients) would be required for AP to be considered cost-effective at £20 000 ($26 600) per quality-adjusted life-year. Annual cost savings of £5.5 to £8.2 million ($7.3-$10.9 million) and health gains >2600 quality-adjusted life-years could be achieved from reinstating AP in England.

CONCLUSIONS

AP is cost-effective for preventing IE, particularly in those at high risk. These findings support the cost-effectiveness of guidelines recommending AP use in high-risk individuals.

Dermatologic manifestations of infective endocarditis

Despite advances in diagnosis and treatment, infective endocarditis still shows considerable morbidity and mortality rates. The dermatological examination in patients with suspected infective endocarditis may prove very useful, as it might reveal suggestive abnormalities of this disease, such as Osler's nodes and Janeway lesions. Osler's nodes are painful, purple nodular lesions, usually found on the tips of fingers and toes. Janeway lesions, in turn, are painless erythematous macules that usually affect palms and soles. We report a case of infective endocarditis and highlight the importance of skin examination as a very important element in the presumptive diagnosis of infective endocarditis.

Comparative Sensitivity of Transthoracic and Transesophageal Echocardiography in Diagnosis of Infective Endocarditis Among Veterans With Staphylococcus aureus Bacteremia

BACKGROUND

Echocardiography is fundamental for diagnosing infective endocarditis (IE) in patients with Staphylococcus aureus bacteremia (SAB), but whether all such patients require transesophageal echocardiography (TEE) is controversial.

METHODS

We identified SAB cases between February 2008 and April 2012. We compared sensitivity and specificity of transthoracic echocardiography (TTE) and TEE for evidence of IE, and we determined impacts of IE risk factors and TTE image quality on comparative sensitivities of TTE and TEE and their impact on clinical decision making.

RESULTS

Of 215 evaluable SAB cases, 193 (90%) had TTE and 130 (60%) had TEE. In 119 cases with both tests, IE was diagnosed in 29 (24%), for whom endocardial involvement was evident in 25 (86%) by TEE, vs only 6 (21%) by TTE (P < .001). Transesophageal echocardiography was more sensitive than TTE regardless of risk factors. Even among the 66 cases with adequate or better quality TTE images, sensitivity was only 4 of 17 (24%) for TTE, vs 16 of 17 (94%) for TEE (P < .001). Among 130 patients with TEE, the TEE results, alone or with TTE results, influenced treatment duration in 56 (43%) cases and led to valve surgery in at least 4 (6%). It is notable that, despite vigorous efforts to obtain both tests routinely, TEE was not done in 86 cases (40%) for various reasons, including pathophysiological contraindications (14%), patient refusal or other patient-related factors (16%), and provider declination or system issues (10%).

CONCLUSIONS

Patients with SAB should undergo TEE when possible to detect evidence for IE, especially if the results might affect management.

Antibiotic Prophylaxis of Infective Endocarditis

Links between infective endocarditis (IE) and dental and other invasive procedures were first identified in the 1920s, and the use of antibiotic prophylaxis (AP) to prevent IE was first recommended by the American Heart Association in 1955. Recognising the weak evidence to support this practice and the wider risks of anaphylaxis and antibiotic resistance, guidelines in the USA and Europe have been rationalised in the last decade with restriction of AP to those patients perceived to be at the highest risk. In the UK, the National Institute for Health and Care Excellence controversially recommended the complete cessation of AP for all invasive procedures in 2008 and subsequent epidemiological studies have suggested a significant increase in cases above the baseline trend. AP appears to be safe and is likely to be cost-effective. Until further data are available, we recommend continued adherence to US and European guidelines.

Is brain angio-MRI useful in infective endocarditis management?

In infective endocarditis (IE), brain magnetic resonance imaging (MRI) is helpful to diagnose clinically silent neurological events. We assessed the usefulness of systematic early brain MRI in IE diagnosis and medico-surgical management. Over a period of 1 year, all patients admitted in one of the three hospitals participating in and fulfilling the Duke criteria for definite or possible IE underwent cerebral MRI within 7 days of IE suspicion. Eight panels of experts analyzed the records a posteriori. For each case, one record with and one record without the MRI results were randomly assigned to two panels, which determined the theoretical diagnosis and treatment. Paired comparisons were performed using a symmetry test. Thirty-seven brain MRIs were performed within a median of 5 days after inclusion. MRI was pathological in 26 patients (70 %), showing 62 % microischemia and 58 % microbleeds. The expert advice did not differ significantly between the two evaluations (with or without the MRI results). The therapeutic strategies determined diverged in five cases (13.5 %). Diagnosis differed in two cases (5.4 %), with an upgrading of diagnosis from possible to definite IE using MRI results. Early brain MRI did not significantly affect the IE diagnosis and medico-surgical treatment plan. These results suggest that systematic use of early brain MRI is irrelevant in IE. Further studies are necessary to define whether MRI is mandatory in IE management within a multidisciplinary approach, with particular attention paid to better timing and the subset of patients in whom this imaging examination could be beneficial.

Clinical significance of hyperhomocysteinemia in infective endocarditis: A case-control study

Blood coagulation plays a key role in the pathogenesis of infective endocarditis (IE). Conditions associated with thrombophilia could enhance IE vegetation formation and promote embolic complications.In this study, we assessed prevalence, correlates, and clinical consequences of hyper-homocysteinemia (h-Hcy) in IE.Homocysteine (Hcy) plasma levels were studied in 246 IE patients and 258 valvular heart disease (VHD) patients, as well as in 106 healthy controls.IE patients showed Hcy levels comparable to VHD patients (14.9 [3-81] vs 16 [5-50] μmol/L, respectively; P = 0.08). H-Hcy was observed in 48.8% of IE patients and 55.8% of VHD (P = 0.13). Vegetation size and major embolic complications were not related to Hcy levels. IE patients with h-Hcy had a higher prevalence of chronic kidney disease and a higher 1-year mortality (19.6% vs 9.9% in those without h-Hcy; OR 2.21 [1.00-4.89], P = 0.05). However, at logistic regression analysis, h-Hcy was not an independent predictor of 1-year mortality (OR 1.87 [95% CI 0.8-4.2]; P = 0.13).Our data suggest h-Hcy in IE is common, is related to a worse renal function, and may be a marker of cardiac dysfunction rather than infection. H-Hcy does not appear to favor IE vegetation formation or its symptomatic embolic complications.

Heart transplantation as salvage therapy for progressive prosthetic valve endocarditis due to methicillin-resistant Staphylococcus epidermidis (MRSE)

BACKGROUND

Prosthetic valve endocarditis (PVE) has the highest in-hospital mortality among all cases of infective endocarditis (IE), it is estimated at about 40 %. Orthotopic heart transplantation (OHT) as a measure of last resort, may be considered in selected cases where repeated surgical procedures and conservative efforts have failed to eradicate persistent or recurrent IE. Only few clinical data are available regarding this rare indication for OHT, since active IE has traditionally been considered as a contraindication for OHT.

CASE PRESENTATION

We report on a 55 year old male patient who underwent prosthetic valve replacement with a mechanical valved conduit ten years ago and developed now persistent PVE with severe complications due to methicillin-resistant Staphylococcus epidermidis (MRSE). Repeated surgical procedures and conservative efforts have failed to eradicate the pathogen. Regarding the lack of curative options, salvage OHT was discussed as a measure of last resort. 28 months after the first diagnosis of PVE, the patient was successfully transplanted and is now doing well under close follow-up (6 months post-OHT).

CONCLUSIONS

PVE remains a challenging condition regarding diagnosis and treatment. The presented case underscores the urgent need for an integrated and multidisciplinary approach to patients with suspected and definitive IE - especially in PVE. OHT might be a feasible measure of last resort in selected patients with IE. Our case report adds published clinical experience to this rarely performed procedure and consolidates previous findings.

Pre-operative stroke and neurological disability do not independently affect short- and long-term mortality in infective endocarditis patients

BACKGROUND

Infective endocarditis (IE) is still associated with high morbidity and mortality. The impact of pre-operative stroke on mortality and long-term survival is controversial. In addition, data on the severity of neurological disability due to pre-operative stroke are scarce. We analysed the impact of pre-operative stroke and the severity of its related neurological disability on short- and long-term outcome.

METHODS

We retrospectively reviewed our data from patients operated for left-sided IE between 01/2007 and 04/2013. We performed univariate (Chi-Square and independent samples t test) and multivariate analyses.

RESULTS

Among 308 consecutive patients who underwent cardiac surgery for left-sided IE, pre-operative stroke was present in 87 (28.2 %) patients. Patients with pre-operative stroke had a higher pre-operative risk profile than patient without it: higher Charlson comorbidity index (8.1 ± 2.6 vs. 6.6 ± 3.3) and higher incidence of Staphylococcus aureus infection (43 vs. 17 %) and septic shock (37 vs. 19 %). In-hospital mortality was equal but 5-year survival was significantly worse with pre-operative stroke (33.1 % vs. 45 %, p = 0.006). 5-year survival was worst in patients with severe neurological disability compared to mild disability (19.0 vs. 0.58 %, p = 0.002). However, neither pre-operative stroke nor the degree of neurological disability appeared as an independent risk factor for short or long-term mortality by multivariate analysis.

CONCLUSIONS

Pre-operative stroke and the severity of neurological disability do not independently affect short- and long-term mortality in patients with infective endocarditis. It appears that patients with pre-operative stroke present with a generally higher risk profile. This information may substantially affect decision-making.

Managing infective endocarditis in the elderly: new issues for an old disease

The incidence of infective endocarditis (IE) rises in industrialized countries. Older people are more affected by this severe disease, notably because of the increasing number of invasive procedures and intracardiac devices implanted in these patients. Peculiar clinical and echocardiographic features, microorganisms involved, and prognosis of IE in elderly have been underlined in several studies. Additionally, elderly population appears quite heterogeneous, from healthy people without past medical history to patients with multiple diseases or who are even bedridden. However, the management of IE in this population has been poorly explored, and international guidelines do not recommend adapting the therapeutic strategy to the patient's functional status and comorbidities. Yet, if IE should be treated according to current recommendations in the healthiest patients, concerns may rise for older patients who suffer from several chronic diseases, especially renal failure, and are on polypharmacy. Treating frailest patients with high-dose intravenous antibiotics during a prolonged hospital stay as recommended for younger patients could also expose them to functional decline and toxic effect. Likewise, the place of surgery according to the aging characteristics of each patient is unclear. The aim of this article is to review the recent data on epidemiology of IE and its peculiarities in the elderly. Then, its management and various therapeutic approaches that can be considered according to and beyond guidelines depending on patient comorbidities and frailty are discussed.

Infective endocarditis requiring ICU admission: epidemiology and prognosis

Background

Very few studies focused on patients with severe infective endocarditis (IE) and multiple complications leading to Intensive Care Unit (ICU) admission. Studied primary outcomes depended on the series and multiple prognostic factors have been identified. Our goal was to determinate characteristics of patients, in-hospital mortality and independent prognostic factors in an overall population of patients admitted to ICU for a left-sided, definite, active and severe IE.

Methods

Retrospective study performed in 9 ICUs during an 11-year period.

Results

Data of 248 patients (mean age = 62.4 ± 13.3 years; 63.7 % male) were studied. Native and prosthetic valves were involved in 195 and 53 patients, respectively. Causative pathogens, identified in 225 patients, were mainly streptococci (45.6 %) and staphylococci (43.4 %). On ICU admission, 127 patients exhibited extra-cardiac involvement. Ninety-five patients had one or more neurological complications, as followed: ischemic stroke (n = 66), cerebral hemorrhage (n = 31), meningitis (n = 16), brain abscess (n = 16), and intracranial mycotic aneurysm (n = 10). Criteria prompting to cardiac surgery appeared during ICU stay for 186 patients and between ICU and hospital discharges in 5 patients. Due to contra-indications, surgery required by IE was only performed during hospitalization in 125 patients. Moreover, surgery was considered adequate according to usual guidelines in 76 of 191 patients with indication(s) of valvular surgery: for patients with surgical procedure considered as emergency (n = 69), 17 surgical procedures underwent within the first 24 h following indication; for patients with urgent surgical indication (n = 102), surgery was performed during the first week following indication in 40 patients; finally, elective surgery (n = 20) was performed for 19 patients. During hospitalization, 103 (41.5 %) patients died. Four independent prognostic factors were identified: SAPS II > 35 (AOR = 2.604; 95 % CI: 1.320–5.136; p = 0.0058), SOFA > 8 (AOR = 3.327; 95 % CI: 1.697–6.521; p = 0.0005), IE due to methicillin resistant Staphylococcus aureus (AOR = 4.981; 95 %CI = 1.433–17.306; p = 0.0115) and native IE (AOR = 0.345; 95 % CI: 0.169–0.703; p = 0.0034).

Conclusions

Mortality in patients admitted to ICU for left-sided IE remains high, especially in cases of endocarditis due to methicillin resistant Staphylococcus aureus, when organ failures occur and ICU scores are high.

Polymicrobial infective endocarditis caused by Neisseria sicca and Haemophilus parainfluenzae

Infective endocarditis is a common clinical problem in industrialized countries. Risk factors include abnormal cardiac valves, a history of endocarditis, intracardiac devices, prosthetic valves and intravenous drug use. We report a case of polymicrobial infective endocarditis in a 33 year-old female with a history chronic heroin use caused by Neisseria sicca and Haemophilus parainfluenzae. We believe the patient was exposed to these microbes by cleansing her skin with saliva prior to injection. Pairing a detailed history with the consideration of atypical agents is crucial in the proper diagnosis and management of endocarditis in patients with high-risk injection behaviors.

Value of brain MRI in infective endocarditis: a narrative literature review

The nervous system is frequently involved in patients with infective endocarditis (IE). A systematic review of the literature was realized in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). This study sought to systematically evaluate the published evidence of the contribution of brain magnetic resonance imaging (MRI) in IE. The aim was to identify studies presenting the incidence and type of MRI brain lesions in IE. Fifteen relevant studies were isolated using the Medline, Embase, and Cochrane databases. Most of them were observational studies with a small number of patients. MRI studies demonstrated a wide variety and high frequency of cerebral lesions, around 80 % of which were mostly clinically occult. This review shows MRI’s superiority compared to brain computed tomography (CT) for the diagnosis of neurologic complications. Recent developments of sensitive MRI sequences can detect microinfarction and cerebral microhemorrhages. However, the clinical significance of these microhemorrhages, also called cerebral microbleeds (CMBs), remains uncertain. Because some MRI neurological lesions are a distinctive IE feature, they can have a broader involvement in diagnosis and therapeutic decisions. Even if cerebral MRI offers new perspectives for better IE management, there is not enough scientific proof to recommend it in current guidelines. The literature remains incomplete regarding the impact of MRI on concerted decision-making. The long-term prognosis of CMBs has not been evaluated to date and requires further studies. Today, brain MRI can be used on a case-by-case basis based on a clinician’s appraisal.

Cytokine Signature in Infective Endocarditis

Infective endocarditis (IE) is a severe disease with high mortality rate. Cytokines participate in its pathogenesis and may contribute to early diagnosis improving the outcome. This study aimed to evaluate the cytokine profile in IE. Serum concentrations of interleukin (IL)-1β, IL-6, IL-8, IL-10, IL-12 and tumor necrosis factor (TNF)-α were measured by cytometric bead array (CBA) at diagnosis in 81 IE patients, and compared with 34 healthy subjects and 30 patients with non-IE infections, matched to the IE patients by age and gender. Mean age of the IE patients was 47±17 years (range, 15–80 years), and 40 (50%) were male. The IE patients had significantly higher serum concentrations of IL-1β, IL-6, IL-8, IL-10 and TNF-α as compared to the healthy individuals. The median levels of IL-1β, TNF-α and IL-12 were higher in the IE than in the non-IE infections group. TNF-α and IL-12 levels were higher in staphylococcal IE than in the non-staphylococcal IE subgroup. There was a higher proportion of both low IL-10 producers and high producers of IL-1β, TNF-α and IL-12 in the staphylococcal IE than in the non-staphylococcal IE subgroup. This study reinforces a relationship between the expression of proinflammatory cytokines, especially IL-1β, IL-12 and TNF-α, and the pathogenesis of IE. A lower production of IL-10 and impairment in cytokine network may reflect the severity of IE and may be useful for risk stratification.

Unusual mechanism of myocardial infarction in prosthetic valve endocarditis

A 46-year-old man with bicuspid aortic valve and severe calcific aortic stenosis was submitted to aortic valve replacement with a stented bioprosthesis. He developed Staphylococcus epidermidis prosthetic valve endocarditis a month later, presenting in the emergency room with acute myocardial infarction. The mechanism of myocardial ischemia was a large aortic root abscess causing left main extrinsic compression. He was urgently taken to the operating room, and an aortic root replacement with cryopreserved homograft was performed, associated with autologous pericardium patch closure of aortic to right atrium fistula and coronary artery bypass grafting of the left anterior descending. After a difficult postoperative period with multiple problems, he was eventually discharged home. At 36-month follow-up, he is asymptomatic with no recurrent infection, and the left main coronary artery is widely patent on control chest computed tomography.

Readmission for infective endocarditis after ischemic stroke or transient ischemic attack

BACKGROUND AND PURPOSE

Providers vary in their thresholds for obtaining blood cultures in patients with ischemic stroke or transient ischemic attack (TIA). We assessed the rate of missed diagnoses of infective endocarditis (IE) in patients discharged with stroke or TIA before blood culture results could have been available.

METHODS

Using administrative claims data, we performed a retrospective cohort study of all patients discharged from nonfederal California emergency departments or acute care hospitals from 2005 through 2011 with stroke (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 433.x1, 434.x1, or 436 in any position) or TIA (ICD-9-CM code 435 in the primary diagnosis position). We excluded patients with a length of stay >2 days to focus on those discharged before conclusive blood culture results could have been available. Our outcome was hospitalization within 14 days with a new diagnosis of IE (ICD-9-CM codes 391.1 or 421.x in any position).

RESULTS

Among 173 966 eligible patients, 24 were subsequently hospitalized for IE-a readmission rate of 1.4 per 10 000 (95% confidence interval [CI], 0.8-1.9 per 10 000). Multiple logistic regression identified the following potential associations with readmission: prosthetic valve: odds ratio (OR), 15.8 (95% CI, 1.9-129.0); other valvular disease: OR, 1.5 (95% CI, 0.2-10.8); urinary tract infection: OR, 3.5 (95% CI, 1.0-12.3; P = .05).

CONCLUSIONS

In patients with acute cerebral ischemia discharged before blood culture results could have been available, the rate of subsequent IE was negligible. These findings argue against the liberal use of blood cultures for the routine evaluation of stroke or TIA.

Neurologic complications in infective endocarditis: identification, management, and impact on cardiac surgery

Neurologic complications of infective endocarditis (IE) are common and frequently life threatening. Neurologic events are not always obvious. The prediction and management of neurologic complications of IE are not easily approached algorithmically, and the impact they have on timing and ability to surgically repair or replace the affected valve often requires a painstaking evaluation and joint effort across multiple medical disciplines in order to achieve the best possible outcome. Although specific recommendations are always tailored to the individual patient, there are some guiding principles that can be used to help direct the decision-making process. Herein, we review the pathophysiology, epidemiology, manifestations, and diagnosis of neurological complications of IE and further consider the impact they have on clinical decision making.

Genetic variants in genes of the inflammatory response in association with infective endocarditis

Aims

Inflammation in infective endocarditis (IE) is a complex network including interactions of inflammatory cytokines and other components of host response. Certainly, any variation in this network could influence susceptibility or disease progression of IE. In this study, 14 single nucleotide variants (SNVs) in genes coding for interleukin-1β, interleukin-6, interleukin-10, toll–like receptor-4, tumor necrosis factor-α, selectin E and intercellular adhesion molecule-1 were analyzed for an association with susceptibility to IE and correlated with disease-related laboratory parameters. Furthermore, the occurrence of SNVs was examined to elucidate pathogen-dependent associations.

Methods and Results

The distribution of SNVs was determined in IE-patients and healthy blood donors by RFLP analysis. White blood cells (WBC) were counted using flow cytometry, concentration of C-reactive protein and procalcitonin was measured immunologically. Interleukin-6 c.471+870G>A genotypes differed significantly between IE patients and controls. The frequency of the heterozygote genotype GA was considerably higher in the patient group (68.9% vs. 43.8%, P_c<0.0003). Interleukin-6 c.-237 minor allele frequency was increased in patients, although not statistically significant. Additionally, we detected a potential relation between interleukin-1β c.315C>T and IE. Pathogen-dependent analysis showed no significantly associated subgroup in relation to IE susceptibility, but gave hints towards alterations regarding Enterococcus-caused IE cases. Patients with genotype selectin-E c.-19 GT tend to have higher preoperative WBC counts than patients with genotype GG. We further showed an association between two interleukin-1β SNVs and laboratory biomarkers.

Conclusion

This study shows genetic predispositions for the establishment of IE. Furthermore, correlation of SNVs with disease-related biomarkers suggests a role of genetic variants regarding the inflammatory response in IE.

Infective endocarditis with left to right intracardiac fistula due to Streptococcus anginosus - a rare complication caused by an even rarer bacterium

Although infective endocarditis (IE) has been described in reports dating from the Renaissance, the diagnosis still challenges and the outcome often surprises. In the course of time, diagnostic criteria have been updated and validated to reduce misdiagnosis. Some risk factors and epidemiology have shown dynamic changes since degenerative valvular disease became more predominant in developed countries, and the mean age of the affected population increased. Despite streptococci have been being well known as etiologic agents, some groups, although rare, have been increasingly reported (e.g., Streptococcus milleri.) Intracardiac complications of IE are common and have a worse prognosis, frequently requiring surgical treatment. We report a case of a middle-aged diabetic man who presented with prolonged fever, weight loss, and ultimately severe dyspnea. IE was diagnosed based on a new valvular regurgitation murmur, a positive blood culture for Streptococcus anginosus, an echocardiographic finding of an aortic valve vegetation, fever, and pulmonary thromboembolism. Despite an appropriate antibiotic regimen, the patient died. Autopsy findings showed vegetation attached to a bicuspid aortic valve with an associated septal abscess and left ventricle and aortic root fistula connecting with the pulmonary artery. A large thrombus was adherent to the pulmonary artery trunk and a pulmonary septic thromboemboli were also identified.