Relapses, recurrences, valve replacements, and mortality during the long-term follow-up after infective endocarditis

Long-term Oral Suppressive Antimicrobial Therapy in Infective Endocarditis (SATIE Study): An Observational Study

Background

The role of suppressive antimicrobial therapy (SAT) in infective endocarditis (IE) management has yet to be defined. The objective of this study was to describe the use of SAT in an IE referral center and the patients' outcomes.

Methods

We conducted a retrospective observational study in a French IE referral center (Paris). All patients with IE who received SAT between 2016 and 2022 were included.

Results

Forty-two patients were included (36 male [86%]; median age [interquartile range {IQR}], 73 [61-82] years). The median Charlson Comorbidity Index score (IQR) was 3 (1-4). Forty patients (95%) had an intracardiac device. The most frequent microorganisms were Enterococcus faecalis (15/42, 36%) and Staphylococcus aureus (12/42, 29%). SAT indications were absence of surgery despite clinical indication (28/42, 67%), incomplete removal of prosthetic material (6/42, 14%), uncontrolled infection source (4/42, 10%), persistent abnormal uptake on nuclear imaging (1/42, 2%), or a combination of the previous indications (3/42, 7%). Antimicrobials were mainly doxycycline (19/42, 45%) and amoxicillin (19/42, 45%). The median follow-up time (IQR) was 398 (194-663) days. Five patients (12%) experienced drug adverse events. Five patients (12%) presented with a second IE episode during follow-up, including 2 reinfections (different bacterial species) and 3 possible relapses (same bacterial species). Fourteen patients (33%) in our cohort died during follow-up. Overall, the 1-year survival rate was 84.3% (73.5%-96.7%), and the 1-year survival rate without recurrence was 74.1% (61.4%-89.4%).

Conclusions

SAT was mainly prescribed to patients with cardiac devices because of the absence of surgery despite clinical indication. Five (12%) breakthrough second IE episodes were reported. Prospective comparative studies are required to guide this empirical practice.

C-terminal deletion of RelA protein is suggested as a possible cause of infective endocarditis recurrence with Enterococcus faecium

Infective endocarditis (IE) caused by Enterococcus spp. represents the third most common cause of IE, with high rates of relapse compared with other bacteria. Interestingly, late relapses (>6 months) have only been described in Enterococcus faecalis, but here we describe the first reported IE relapse with Enterococcus faecium more than a year (17 months) after the initial endocarditis episode. Firstly, by multi locus sequence typing (MLST), we demonstrated that both isolates (EF646 and EF641) belong to the same sequence type (ST117). Considering that EF641 was able to overcome starvation and antibiotic treatment conditions surviving for a long period of time, we performed bioinformatic analysis in identifying potential genes involved in virulence and stringent response. Our results showed a 13-nucleotide duplication (positions 1638-1650) in the gene relA, resulting in a premature stop codon, with a loss of 167 amino acids from the C-terminal domains of the RelA enzyme. RelA mediates the stringent response in bacteria, modulating levels of the alarmone guanosine tetraphosphate (ppGpp). The relA mutant (EF641) was associated with lower growth capacity, the presence of small colony variants, and higher capacity to produce biofilms (compared with the strain EF646), but without differences in antimicrobial susceptibility patterns according to standard procedures during planktonic growth. Instead, EF641 demonstrated tolerance to high doses of teicoplanin when growing in a biofilm. We conclude that all these events would be closely related to the long-term survival of the E. faecium and the late relapse of the IE. These data represent the first clinical evidence of mutations in the stringent response (relA gene) related with E. faecium IE relapse.

Recurrence of bacteremia and infective endocarditis according to bacterial species of index endocarditis episode

PURPOSE

In patients surviving infective endocarditis (IE) recurrence of bacteremia or IE is feared. However, knowledge is sparse on the incidence and risk factors for the recurrence of bacteremia or IE.

METHODS

Using Danish nationwide registries (2010-2020), we identified patients with first-time IE which were categorized by bacterial species (Staphylococcus aureus, Enterococcus spp., Streptococcus spp., coagulase-negative staphylococci [CoNS], 'Other' microbiological etiology). Recurrence of bacteremia (including IE episodes) or IE with the same bacterial species was estimated at 12 months and 5 years, considering death as a competing risk. Cox regression models were used to compute adjusted hazard ratios of the recurrence of bacteremia or IE.

RESULTS

We identified 4086 patients with IE; 1374 (33.6%) with S. aureus, 813 (19.9%) with Enterococcus spp., 1366 (33.4%) with Streptococcus spp., 284 (7.0%) with CoNS, and 249 (6.1%) with 'Other'. The overall 12-month incidence of recurrent bacteremia with the same bacterial species was 4.8% and 2.6% with an accompanying IE diagnosis, while this was 7.7% and 4.0%, respectively, with 5 years of follow-up. S. aureus, Enterococcus spp., CoNS, chronic renal failure, and liver disease were associated with an increased rate of recurrent bacteremia or IE with the same bacterial species.

CONCLUSION

Recurrent bacteremia with the same bacterial species within 12 months, occurred in almost 5% and 2.6% for recurrent IE. S. aureus, Enterococcus spp., and CoNS were associated with recurrent infections with the same bacterial species.

Absence of infective endocarditis relapse when end-of-treatment fluorodeoxyglucose positron emission tomography/computed tomography is negative

AIMS

In non-operated infective endocarditis (IE), relapse may impair the outcome of the disease. The aim of the study was to evaluate the relationship between end-of-treatment (EOT) fluorodeoxyglucose positron emission tomography/computed tomography FDG-PET/CT results and relapse in non-operated IE either on native or prosthetic valve.

METHODS AND RESULTS

We included 62 patients who underwent an EOT FDG-PET/CT for non-operated IE performed between 30 and 180 days of antibiotic therapy initiation. Qualitative valve assessment categorized initial and EOT FDG-PET/CT as negative or positive. Quantitative analyses were also conducted. Clinical data from medical charts were collected, including endocarditis team decision for IE diagnosis and relapse. Forty-one (66%) patients were male with a median age of 68 years (57; 80) and 42 (68%) had prosthetic valve IE. End-of-treatment FDG-PET/CT was negative in 29 and positive in 33 patients. The proportion of positive scans decreased significantly compared with initial FDG-PET/CT (53% vs. 77%, respectively, P < 0.0001). All relapses (n = 7, 11%) occurred in patients with a positive EOT FDG-PET/CT with a median delay after EOT FDG-PET/CT of 10 days (0; 45). The relapse rate was significantly lower in negative (0/29) than in positive (7/33) EOT FDG-PET/CT (P = 0.01).

CONCLUSION

In this series of 62 patients with non-operated IE who underwent EOT FDG-PET/CT, those with a negative scan (almost half of the study population) did not develop IE relapse after a median follow-up of 10 months. These findings need to be confirmed by prospective and larger studies.

Multiple Recurrent Infective Endocarditis Secondary to Streptococcus mitis Bacteremia Despite Proper Antibiotic and Surgical Treatment

Infective endocarditis (IE) is a rare and potentially fatal disease. It is an infection of the endocardium of the heart and heart valves. One of the major complications faced by patients who have recovered from a first episode of IE is recurrent IE. Risk factors for recurrent IE include intravenous (IV) drug use, prior episodes of IE, poor dentition, recent dental procedures, male gender, age over 65, prosthetic heart valve endocarditis, chronic dialysis, positive valve culture(s) obtained at the time of surgical intervention, and persistent postoperative fever. We present a case of a 40-year-old male with a history of former IV heroin use who experienced multiple episodes of recurrent IE caused by the same pathogen, Streptococcus mitis. This recurrence occurred despite the patient completing the appropriate course of antibiotic therapy, undergoing valvular replacement, and maintaining drug abstinence for two years. This case highlights the challenges associated with identifying the source of infection and emphasizes the need to develop guidelines for surveillance and prophylaxis against recurrent IE.

Clinical profile and outcome of recurrent infective endocarditis

AIMS

Purpose of this study is to compare the clinical course and outcome of patients with recurrent versus first-episode infective endocarditis (IE).

METHODS

Patients with recurrent and first-episode IE enrolled in the EUROpean ENDOcarditis (EURO-ENDO) registry including 156 centres were identified and compared using propensity score matching. Recurrent IE was classified as relapse when IE occurred ≤6 months after a previous episode or reinfection when IE occurred >6 months after the prior episode.

RESULTS

3106 patients were enrolled: 2839 (91.4%) patients with first-episode IE (mean age 59.4 (±18.1); 68.3% male) and 267 (8.6%) patients with recurrent IE (mean age 58.1 (±17.7); 74.9% male). Among patients with recurrent IE, 13.2% were intravenous drug users (IVDUs), 66.4% had a repaired or replaced valve with the tricuspid valve being more frequently involved compared with patients with first-episode IE (20.3% vs 14.1%; p=0.012). In patients with a first episode of IE, the aortic valve was more frequently involved (45.6% vs 39.5%; p=0.061). Recurrent relapse and reinfection were 20.6% and 79.4%, respectively. Staphylococcus aureus was the microorganism most frequently observed in both groups (p=0.207). There were no differences in in-hospital and post-hospitalisation mortality between recurrent and first-episode IE. In patients with recurrent IE, in-hospital mortality was higher in IVDU patients. Independent predictors of poorer in-hospital and 1-year outcome, including the occurrence of cardiogenic and septic shock, valvular disease severity and failure to undertake surgery when indicated, were similar for recurrent and first-episode IE.

CONCLUSIONS

In-hospital and 1-year mortality was similar in patients with recurrent and first-episode IE who shared similar predictors of poor outcome.

Endocardite Infecciosa: Ainda mais Desafios que Certezas

Após catorze décadas de evolução médica e tecnológica, a endocardite infeciosa continua a desafiar médicos no seu diagnóstico e manejo diário. O aumento da incidência, alterações demográficas (afetando pacientes mais idosos), microbiologia com taxas de infeção por Staphylococcus mais elevadas, com complicações graves ainda frequentes e uma mortalidade substancial tornam a endocardite uma doença muito complexa. Apesar de tudo, a inovação no seu diagnóstico, nomeadamente na área da microbiologia e imagem, e a melhoria nos cuidados intensivos e na cirurgia cardíaca (quanto às técnicas, materiais usados e momento de intervenção) podem ter um impacto no seu prognóstico. Os desafios persistem, incluindo repensar a profilaxia, melhorar os critérios de diagnóstico incluindo a endocardite com culturas negativas e endocardite de prótese valvar, o timing para a intervenção cirúrgica, e sua realização ou não na presença de acidente vascular cerebral isquêmico e em usuários de drogas intravenosas. Uma estratégia combinada na endocardite infeciosa é fundamental, incluindo decisões e protocolos clínicos avançados, um manejo multidisciplinar, organização e políticas de saúde que culminem em melhores resultados para os nossos pacientes.

Current recommendations and uncertainties for surgical treatment of infective endocarditis: a comparison of American and European cardiovascular guidelines

Surgery is an effective therapy in the treatment of left-sided infective endocarditis (IE) in patients for whom antibiotic treatment alone is unlikely to be curative or may be associated with ongoing risk of complications. However, the interplay between indication for surgery, its risk, and timing is complex and there continue to be challenges in defining the effects of surgery on disease-related outcome. Guidelines published by the American College of Cardiology/American Heart Association and the European Society of Cardiology provide recommendations for the use of surgery in IE, but these are limited by a low level of evidence related to predominantly observational studies with inherent selection and survival biases. Evidence to guide the timing of surgery in IE is less robust, and predominantly based on expert consensus. Delays between IE diagnosis and recognition of an IE complication as a surgical indication and transfers to surgical centres also impact surgical timing. This comparison of the two guidelines exposes areas of uncertainty and gaps in current evidence for the use of surgery in IE across different indications, particularly related to its timing and consideration of operative risk.

Clinical predictors of outcome in patients with infective endocarditis receiving outpatient parenteral antibiotic therapy (OPAT)

OBJECTIVES

Outpatient parenteral antimicrobial therapy (OPAT) is increasingly used to treat infective endocarditis (IE) with documented success. This study aims to identify risk factors for treatment failure and poor outcomes in patients with IE treated through OPAT.

METHODS

We conducted a retrospective analysis of all episodes of IE treated over 13 years (September 2006 - September 2019) at a large teaching hospital in Sheffield, UK. We defined OPAT failure as unplanned readmission or death within 30 days of discharge from the OPAT service. Major adverse cardiac events (MACE) were defined as a composite of IE-related death, cardiac surgery, and recurrence of IE within the first year of completion of OPAT.

RESULTS

Overall, 168 episodes of IE were reviewed. OPAT failure and MACE occurred in 44 episodes (26.2%) and 29 episodes (17.3%) respectively. On multivariable analysis, pre-existing renal failure (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.08-8.30; P = 0.034) and Charlson comorbidity score (aOR, 1.29 per unit increase; 95% CI, 1.06-1.57; P = 0.011) were associated with increased risk of failure. Previous endocarditis (aOR, 3.60; 95% CI, 1.49-8.70; P = 0.004) and cardiac complications (aOR, 3.85; 95% CI, 1.49-9.93; P = 0.005) were risk factors for MACE, whereas cardiac surgery during the initial hospitalisation for IE (aOR, 0.34; 95% CI, 0.12-0.22; P < 0.001) was a protective factor.

CONCLUSIONS

Our findings suggest that OPAT is safe and effective for completing antibiotic treatment for IE, including cases deemed to be at increased risk of complications. However, careful patient selection and monitoring of patients with pre-existing comorbidities and cardiac complications are recommended to optimise clinical outcomes.

Antibiotika im Rahmen der Endokarditisprophylaxe – Risiko und Nutzen

Für die Effektivität und Effizienz einer antibiotischen Prophylaxe vor zahnmedizinischen Eingriffen zum Schutz vor einer infektiösen Endokarditis liegt nur eine geringe Evidenz vor, die keine Rechtfertigung zur generalisierten Therapie von Patienten mit einem erhöhten Endokarditisrisiko darstellt. Aktuelle Leitlinien empfehlen daher, Antibiotika im Rahmen der Endokarditisprophylaxe auf Patienten zu beschränken, die zum einen ein hohes Risiko für die Entstehung einer infektiösen Endokarditis aufweisen und die sich zum anderen zahnärztlichen Eingriffen mit höchstem Endokarditisrisiko unterziehen. Einen hohen Stellwert besitzen allerdings auch Mund- und Hauthygienemaßnahmen, die nicht nur auf Risikopatienten, sondern auch auf die Allgemeinbevölkerung angewendet werden sollten, da die Inzidenz der infektiösen Endokarditis bei Patienten ohne anamnestisch bekannte Herzerkrankung zunehmend ansteigt.

Risk Factors for Mortality in an Older Veteran Population With infective Endocarditis

OBJECTIVE

To determine 30-day and 1-year mortality in patients treated for infective endocarditis (IE) in a VA population. The secondary objective was to identify risk factors for increased risk of mortality in veterans diagnosed with IE.

DESIGN

A retrospective cohort study.

SETTING

Veterans Affairs Western New York Healthcare System PARTICIPANTS: Patients who had a diagnosis of IE between the years 2005 and 2016. Patients were identified via International Classification of Diseases (ICD) codes.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Factors for death and survival were compared using a bivariate analysis. Significant factors were built into a multivariate logistic regression analysis to determine risk factors for death at 30 days and 1 year.

RESULTS

Between 2005 and 2016, there were 153 patients with IE. All-cause mortality at 30 days was 14% versus 39% at 1 year. Patients were more likely to die at 1 year with higher Pitt Bacteremia Scores, older age, and lower number of minor criteria according to Duke Criteria. Comorbidities were similar between groups.

CONCLUSIONS

Older patients with higher Pitt Bacteremia Scores and lower numbers of minor criteria are more likely to experience mortality at one year. Given the high rates of death at one year, close monitoring, even after completion of therapy may be necessary in older patients. Senior care pharmacists are in a unique position to monitor these patients.

Burden of infective endocarditis in an Australian cohort of people who inject drugs

BACKGROUND

Infective endocarditis (IE) results in substantial morbidity and mortality in people who inject drugs (PWID).

AIMS

To describe the burden of IE and its outcomes in PWID.

METHODS

Retrospective cohort study of adults admitted to a tertiary referral centre in Melbourne, Australia, with IE due to injection drug use from 1997 to 2015.

RESULTS

Ninety-seven PWID with 127 episodes of IE were identified with a median acute inpatient stay of 37 days (1-84). Admission to an intensive care unit was required in 67/127 (53%) episodes. Twenty-seven percent (34/127) of episodes occurred in patients with a previous episode of endocarditis. One third (43/127, 34%) of episodes involved left-sided cardiac valves. Antimicrobial treatment was completed in 88 (70%) episodes. Valve surgery was performed in 25/127 (20%) episodes. Predictors of surgery in univariable analysis were left-sided cardiac involvement (risk ratio (RR) 6.0), severe valvular regurgitation (RR 2.6) and cardiac failure (RR 2.2) (all P < 0.005). Twenty (16%) episodes resulted in death. Predictors of mortality on univariable analysis were left-sided cardiac involvement (RR 6.4), and not completing treatment (RR 0.12; both P < 0.001). The average estimated cost per episode was AU$74 168.

CONCLUSIONS

IE causes a considerable burden of disease in PWID, with significant healthcare utilisation and cost. Surgery and death are not infrequent complications. In addition to ensuring completion of antimicrobial therapy, strategies such as opioid maintenance programmes may be useful in improving health outcomes for PWID.

Long-term Outcome of Patients With Nonoperated Prosthetic Valve Infective Endocarditis: Is Relapse the Main Issue?

In nonoperated prosthetic valve endocarditis (PVE), long-term outcome is largely unknown. We report the follow-up of 129 nonoperated patients with PVE alive at discharge. At 1 year, the mortality rate was 24%; relapses and reinfection were rare (5% each). Enterococcal PVE was associated with a higher risk of relapse.

Clinical Factors Associated with Reinfection versus Relapse in Infective Endocarditis: Prospective Cohort Study

We aimed to identify clinical factors associated with recurrent infective endocarditis (IE) episodes. The clinical characteristics of 2816 consecutive patients with definite IE (January 2008–2018) were compared according to the development of a second episode of IE. A total of 2152 out of 2282 (94.3%) patients, who were discharged alive and followed-up for at least the first year, presented a single episode of IE, whereas 130 patients (5.7%) presented a recurrence; 70 cases (53.8%) were due to other microorganisms (reinfection), and 60 cases (46.2%) were due to the same microorganism causing the first episode. Thirty-eight patients (29.2%), whose recurrence was due to the same microorganism, were diagnosed during the first 6 months of follow-up and were considered relapses. Relapses were associated with nosocomial endocarditis (OR: 2.67 (95% CI: 1.37–5.29)), enterococci (OR: 3.01 (95% CI: 1.51–6.01)), persistent bacteremia (OR: 2.37 (95% CI: 1.05–5.36)), and surgical treatment (OR: 0.23 (0.1–0.53)). On the other hand, episodes of reinfection were more common in patients with chronic liver disease (OR: 3.1 (95% CI: 1.65–5.83)) and prosthetic endocarditis (OR: 1.71 (95% CI: 1.04–2.82)). The clinical factors associated with reinfection and relapse in patients with IE appear to be different. A better understanding of these factors would allow the development of more effective therapeutic strategies.

Long-term follow-up of patients with infective endocarditis in a tertiary referral center

BACKGROUND

Infective endocarditis (IE) remains a severe disease with high mortality. Most studies report on short-term outcome while real world long-term outcome data are scarce. This study reports reinfection rates and mortality data during long-term follow-up.

METHODS

A total of 270 patients meeting the modified Duke criteria for definite IE admitted to a tertiary care center between July 2000 and June 2007 were analyzed retrospectively. Early reinfection was defined as a new IE episode within 6 months; late reinfection as a new IE episode beyond 6 months follow-up.

RESULTS

Median follow-up was 8.5 years. Early reinfection occurred in 10 patients (3.7%), late reinfection in 18 patients (6.7%). Staphylococci (39.7%) were the most frequent causative microorganisms, followed by Streptococci (30.0%) and Enterococci (17.8%). Independent predictors of any reinfection were heart failure (HR 3.02, 95% CI 1.42-6.41), peripheral embolization (HR 4.00, 95% CI 1.58-10.17) and implanted pacemakers (HR 3.43, 95% CI 1.25-9.36). Survival rates were 71.1%, 55.2% and 43.3% at respectively 1-, 5- and 10-years follow-up. Independent predictors for mortality were age (HR 1.03, 95% CI 1.01-1.04), diabetes mellitus (HR 2.24, 95% CI 1.46-3.45), hemodialysis (HR 2.70, 95% CI 1.37-5.29), heart failure (HR 1.64, 95% CI 1.19-2.26), stroke (HR 1.73, 95% CI 1.18-2.52), antimicrobial treatment despite surgical indication (HR 5.53, 95% CI 3.59-8.49) and non-Streptococci causative microorganisms (HR 1.84, 95% CI 1.28-2.64).

CONCLUSIONS

Contemporary mortality rates of infective endocarditis remain high, irrespective of reinfection. Heart failure, peripheral embolization and presence of a pacemaker were predictors of reinfection.

Comparative Surgical Outcomes of Prosthetic and Native Valve Endocarditis

In the present study, the patterns and clinical outcomes of prosthetic valve endocarditis (PVE) surgery were analyzed as compared with native valve endocarditis (NVE). The proportion of PVE among surgical infective endocarditis increased gradually through the study period. Patients with PVE was characterized by old age and more extensive infective lesions. PVE group showed notably higher early and overall mortality, and valve reinfection as well. PVE carried significant perioperative risks, and was an independent risk factor of overall mortality.

Background and Objectives

As a consequence of a growing number of patients undergoing prosthetic heart valve replacement, the incidence of prosthetic valve endocarditis (PVE) has increased. The study aims to analyze patterns and outcomes of PVE surgery as compared with native valve endocarditis (NVE).

Methods

We enrolled 269 patients (aged 58.0±15.7 years) who underwent valve surgery for infective endocarditis (IE) between 2013 and 2019. Of these, 56 had PVE whereas remainder (n=213) had NVE. Clinical outcomes were compared and multivariable analyses were conducted to determine risk factors for mortality.

Results

The proportion of PVE among surgical IE gradually increased from 15.4% (11/71) in the first time-quartile to 29.5% (18/61) in the last time-quartile (p=0.055). PVE patients were older, and more commonly had aorto-mitral curtain involvement and abscess formation than NVE group. Early mortality was 14.3% and 6.1% in PVE and NVE group, respectively (p=0.049). Postoperatively, PVE group had higher incidences of low cardiac output syndrome (p=0.027), new-onset dialysis (p=0.006) and reoperation for bleeding (p=0.004) compared to NVE group, but stroke rates were comparable (p=0.503). During follow-up (648.8 patient-years), PVE group showed significantly higher risks of overall mortality (p<0.001), valve reinfection (p<0.001) and permanent pacemaker implantation (p<0.001) than NVE group. On multivariable analysis, PVE (hazard ratio, 2.67; 95% confidence interval, 1.40–5.07; p=0.003) along with age, chronic kidney disease, multi-valve involvement, and causative organisms of Staphylococcus aureus or fungus were independent risk factors of overall mortality.

Conclusions

PVE carried significant perioperative risks, and was an independent risk factor of overall mortality.

Thirty-Day Readmission After Infective Endocarditis: Analysis From a Nationwide Readmission Database

Background

The contemporary incidence of and reasons for early readmission after infective endocarditis (IE) are not well known. Therefore, we analyzed 30‐day readmission demographics after IE from the US Nationwide Readmission Database.

Methods and Results

We examined the 2010 to 2014 Nationwide Readmission Database to identify index admissions for a primary diagnosis of IE with survival at discharge. Incidence, reasons, and independent predictors of 30‐day unplanned readmissions were analyzed. In total, 11 217 patients (24.8%) were nonelectively readmitted within 30 days among the 45 214 index admissions discharged after IE. The most common causes of readmission were IE (20.5%), sepsis (8.7%), complications of device/graft (8.1%), and congestive heart failure (7.6%). In‐hospital mortality and the valvular surgery rates during the readmissions were 8.1% and 9.1%, respectively. Discharge to home or self‐care, undergoing valvular surgery, aged ≥60 years, and having private insurance were independently associated with lower rates of 30‐day readmission. Length of stay of ≥10 days, congestive heart failure, diabetes mellitus, renal failure, chronic pulmonary disease, peripheral artery disease, and depression were associated with higher risk. The total hospital costs of readmission were $48.7 million per year (median, $11 267; interquartile range, $6021–$25 073), which accounted for 38.6% of the total episodes of care (index+readmission).

Conclusions

Almost 1 in 4 patients was readmitted within 30 days of admission for IE. The most common reasons were IE, other infectious causes, and cardiac causes. A multidisciplinary approach to determine the surgical indications and close monitoring are necessary to improve outcomes and reduce complications in in‐hospital and postdischarge settings.

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.

Contemporary epidemiology and outcomes in recurrent infective endocarditis

Objective

Recurrent infective endocarditis (IE) is a major complication of patients surviving a first episode of IE. This study sought to analyse the current state of recurrent IE in a large contemporary cohort.

Methods

1335 consecutive episodes of IE were recruited prospectively in three tertiary care centres in Spain between 1996 and 2015. Episodes were categorised into group I (n=1227), first-IE episode and group II (n=108), recurrent IE (8.1%). After excluding six patients, due to lack of relevant data, group II was subdivided into IIa (n=87), reinfection (different microorganism), and IIb (n=15), relapse (same microorganism within 6 months of the initial episode).

Results

The cumulative burden and incidence of recurrence was slightly lower in the second decade of the study (2006–2015) (7.17 vs 4.10 events/100 survivors and 7.51% vs 3.82, respectively). Patients with reinfections, compared with group I, were significantly younger, had a higher frequency of HIV infection, were more commonly intravenous drug users (IVDU) and prosthetic valve carriers, had less embolic complications and cardiac surgery, with similar in-hospital mortality. IVDU was found to be an independent predictor of reinfection (HR 3.92, 95% CI 1.86 to 8.28).

In the relapse IE group, prosthetic valve endocarditis (PVE) and periannular complications were more common. Among patients treated medically, those with PVE had a higher relapse incidence (4.82% vs 0.43% in native valve IE, p=0.018). Staphylococcus aureus and PVE were independent predictors of relapse (HR 3.14, 95% CI 1.11 to 8.86 and 3.19, 95% CI 1.13 to 9.00, respectively) and in-hospital-mortality was similar to group I. Three-year all-cause mortality was similar in recurrent episodes compared with single episodes.

Conclusion

Recurrent IE remains a frequent late complication. IVDU was associated with a fourfold increase in the risk of reinfection. PVE treated medically and infections caused by S. aureus increased the risk of relapse. In-hospital and long-term mortality was comparable among groups.

Recurrent Endocarditis in Persons Who Inject Drugs

Background

Infective endocarditis (IE) is increasing among persons who inject drugs (PWID) and has high morbidity and mortality. Recurrent IE in PWID is not well described.

Methods

This was a retrospective cohort study conducted between February 2007 and March 2016. It included adult inpatients (≥18) at any of 3 tertiary care centers in London, Ontario, with definite IE based on the Modified Duke's Criteria. The objectives were to characterize recurrent IE in PWID, identify risk factors for recurrent IE, identify the frequency of fungal endocarditis, and establish whether fungal infection was associated with higher mortality.

Results

Three hundred ninety patients had endocarditis, with 212/390 in PWID. Sixty-eight of 212 (32%) PWID had a second episode, with 28/212 (12%) having additional recurrences. Second-episode IE was more common in PWID (11/178 [6.2%] vs 68/212 [32.1%]; P < .001). Peripherally inserted central catheter (PICC) line abuse was associated with increased risk of recurrent endocarditis (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.01–3.87; P = .04). In PWID, fungal IE was more common in second episodes than first episodes (1/212 [0.5%] vs 5/68 [7.4%]; P = .004). Additionally, fungal infections were associated with mortality in second-episode IE in PWID with an adjusted OR of 16.49 (95% CI, 1.12–243.17; P = .041). Despite recurrent infection, likely due to continued drug use, there was a low rate of referral to addiction treatment (14/68 [20.6%]).

Conclusions

PWID have a high risk of recurrent endocarditis, particularly in patients who abuse PICC lines. Fungal endocarditis is more common in second-episode endocarditis and is associated with increased mortality. Consideration of empiric antifungal therapy in PWID with IE history and suspected IE should be considered.

Dehiscence and embolization of CorMatrix tricuspid valve replacement in the setting of infective endocarditis: a case report

Background

Due to increased morbidity and mortality, prosthetic valve infective endocarditis (IE) with dehiscence requires urgent intervention. Early identification and therapy may prevent embolization.

Case summary

A 27-year-old Caucasian woman with a history of hepatitis C, intravenous drug abuse, and tricuspid valve (TV) replacement was admitted for recurrent IE. She was found to have bacteraemia and fungaemia, and empiric antibiotics were initiated. Transthoracic echocardiogram (TTE) revealed a mobile ‘mass’ on the TV and dehiscence. The patient developed cardiogenic shock and repeat TTE showed a ruptured TV and absence of the ‘mass’, suspicious of embolization. She underwent emergent surgery with TV replacement using a Biocor valve and retrieval of the old CorMatrix valve found in the right mid pulmonary artery (PA). The patient was successfully weaned off inotropic agents and completed a prolonged course of antibiotics and anti-fungals.

Discussion

The multi-disciplinary decision on timing of surgical intervention was challenging, especially due to ongoing mycobacterial infection that increased operative risk. With clinical deterioration, urgent surgery was performed revealing an embolized prosthetic valve in the PA. New surgical options for TV replacement in IE with extracellular-based material have shown promising outcomes with little reported data of long term complications. This case demonstrates a rare occurrence of embolized CorMatrix TV and highlights the challenge in timing of appropriate surgical intervention in a septic patient with thrombocytopenia.

Benefit of Echocardiography in Patients With Staphylococcus aureus Bacteremia at Low Risk of Endocarditis

Background

The risk of endocarditis among patients with Staphylococcus aureus bacteremia is not uniform, and a number of different scores have been developed to identify patients whose risk is less than 5%. The optimal echocardiography strategy for these patients is uncertain.

Methods

We used decision analysis and Monte Carlo simulation using input parameters taken from the existing literature. The model examined patients with S aureus bacteremia whose risk of endocarditis is less than 5%, generally those with nosocomial or healthcare-acquired bacteremia, no intracardiac prosthetic devices, and a brief duration of bacteremia. We examined 6 echocardiography strategies, including the use of transesophageal echocardiography, transthoracic echocardiography, both modalities, and neither. The outcome of the model was 90-day survival.

Results

The optimal echocardiography strategy varied with the risk of endocarditis and the procedural mortality associated with transesophageal echocardiography. No echocardiography strategy offered an absolute benefit in 90-day survival of more than 0.5% compared with the strategy of not performing echocardiography and treating with short-course therapy. Strategies using transesophageal echocardiography were never preferred if the mortality of this procedure was greater than 0.5%.

Conclusions

In patients identified to be at low risk of endocarditis, the choice of echocardiography strategy appears to exert a very small influence on 90-day survival. This finding may render test-treatment trials unfeasible and should prompt clinicians to focus on other, more important, management considerations in these patients.

Repeat Infective Endocarditis in Persons Who Inject Drugs: "Take Another Little Piece of my Heart"

Background

Injection drug use (IDU) is a major risk factor for infective endocarditis (IE). Few data exist on repeat IE (rIE) in persons who inject drugs (PWID).

Methods

Patients ≥18 years old seen at Wake Forest Baptist Medical Center from 2004 to 2017 who met Duke criteria for IE and who self-reported IDU in the 3 months before admission were identified. The subset of PWID who developed rIE, defined as another episode of IE at least 10 weeks after diagnosis of the first episode, was then reviewed.

Results

Of the 87 PWID who survived their first episode of IE, 22 (25.3%) experienced rIE and 77.3% had rIE within a year of the first episode. All patients who experienced rIE resumed IDU between episodes of IE. Of the patients with rIE, 54.5% had an infection caused by S. aureus and 22.7% required surgical intervention. Mortality at 1 year was 36.3%. Compared with their first IE episode, patients with rIE had fewer S. aureus infections (P = .01). Compared with PWID who experienced single-episode IE, intravenous prescription opioid use (P = .01), surgery (P < .01), tricuspid valve involvement (P = .02), and polymicrobial infection (P = .03) occurred more often during first episodes of IE in individuals who then developed rIE.

Conclusions

rIE is common among IDU-related IE and confers a high 1-year mortality rate. The microbiology of rIE is varied, with S. aureus being less frequently isolated. More studies on modification of social and clinical risk factors are needed to prevent rIE.

Diagnostic accuracy of transthoracic echocardiography to identify native valve infective endocarditis: a systematic review and meta-analysis

Infective endocarditis (IE) is a serious and potentially life-threatening disease, and accurate diagnosis is essential. We performed a systematic review and meta-analysis to assess the diagnostic accuracy of transthoracic echocardiography (TTE), with transesophageal echocardiography (TEE) as the reference standard, in patients with suspected IE of the native valves. We performed a systematic search in MEDLINE, EMBASE and Cochrane Library searching for studies that enrolled adult patients with suspected native valves IE where data about both TTE and TEE could be extracted. We included 11 studies, for a total of 2209 patients. The overall sensitivity, specificity, negative and positive likelihood ratios (LR) of TTE are 0.71 (95% CI 0.56-0.82), 0.80 (95% CI 0.58-0.92), 0.37 (95% CI 0.20-0.68) and 3.56 (95% CI 1.3-9.72), respectively. The subgroup analyses of the studies considering different cut-off levels show that the strict negative criteria (i.e., managing indeterminate results as positive) have the highest sensitivity and the lowest LR-. On the contrary, when managing indeterminate results as negative (standard criteria), the specificity and LR+ are the highest. We observed no differences between the studies performed with older and more recent technologies. In conclusion, our study results support the use of a negative TTE as a single rule-out test in patients with a low pre-test probability. In selected cases, the use of strict negative criteria might exclude IE in intermediate-risk patients, and a positive TTE might be considered as a single rule-in test with no need for TEE if TEE results would not change the patient's management.

What risk of endocarditis is low enough to justify the omission of transoesophageal echocardiography in Staphylococcus aureus bacteraemia? A narrative review

BACKGROUND

Recent criteria which can identify patients with Staphylococcus aureus bacteraemia (SAB) who are at very low risk of endocarditis raise the question of whether transoesophageal echocardiography (TOE) is appropriate for these patients.

AIMS

To estimate the probability of occult endocarditis complicating SAB below which a TOE-guided treatment strategy no longer offers the best 180-day survival, and to examine the key uncertainties affecting this result.

SOURCES

Estimates of the parameters required to calculate the Pauker-Kassirer testing threshold were identified from studies published prior to 1 June 2017 using a composite search strategy that involved a systematic search for relevant controlled trials and guidelines, followed by a non-systematic iterative search of the observational literature.

CONTENT

Estimates of the necessary parameters were generally consistent across the literature with the exception of the procedural mortality of TOE. In our base-case scenario (TOE mortality 0.1%), the testing threshold for TOE in apparently uncomplicated SAB was a 1.1% probability of occult endocarditis. Sensitivity analyses revealed that the procedural mortality of TOE was a key uncertainty affecting estimates of the testing threshold.

IMPLICATIONS

None of the available clinical tools can place patients with SAB below this probability of endocarditis with 95% confidence. Future work in this area should concentrate on improving the precision of these tools and on exploring the value of alternative echocardiography strategies. In addition, a better understanding of the harms of TOE is required to ensure that recommendations regarding the role of this investigation in the management of patients with SAB are appropriate.

The "3M" Approach to Cardiovascular Infections: Multimodality, Multitracers, and Multidisciplinary

Cardiovascular infections are associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient management, as early treatment improves the prognosis. The diagnosis cannot be made on the basis of a single symptom, sign, or diagnostic test. Rather, the diagnosis requires a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data, and imaging data. The application of multimodality imaging, including molecular imaging techniques, has improved the sensitivity to detect infections involving heart valves and vessels and implanted cardiovascular devices while also allowing for early detection of septic emboli and metastatic infections before these become clinically apparent. In this review, we describe data supporting the use of a Multimodality, Multitracer, and Multidisciplinary approach (the 3M approach) to cardiovascular infections. In particular, the role of white blood cell SPECT/CT and [¹⁸F]FDG PET/CT in most prevalent and clinically relevant cardiovascular infections will be discussed. In addition, the needs of advanced hybrid equipment, dedicated imaging acquisition protocols, specific expertise for image reading, and interpretation in this field are discussed, emphasizing the need for a specific reference framework within a Cardiovascular Multidisciplinary Team Approach to select the best test or combination of tests for each specific clinical situation.

Bacteremia Associated With Oral Surgery: A Review

OBJECTIVES

Bacterial (infective) endocarditis, a microbial infection of the endocardium surfaces after bacteremia, causes significant morbidity and mortality. Recent epidemiologic studies have reported a prevalence of 2-8 cases per 100,000 individuals per year, with the highest incidence in those aged 70-80 years and those living in developed countries. We systematically reviewed the literature on several critical aspects regarding the development of bacteremia after oral surgery. The purpose of this work is to assess the controversy regarding antibiotic prophylaxis before oral surgery.

MATERIALS AND METHODS

Publications between 1976 and 2015 were included. Clinical studies focusing on oral surgery as the underlying cause were included.

RESULTS

Among the 32 clinical studies reviewed, 3564 cases, accounting for 12,839 blood cultures, were evaluated. In 10 of these studies, amoxicillin usefulness was studied. Antimicrobial prophylaxis before an invasive dental procedure does not prevent bacteremia, although it can decrease both its magnitude and its persistence.

CONCLUSIONS

The highly conflicting data and conclusions of the analyzed work highlight the need for new approaches to the study of bacteremia that would provide reliable evidence and thus appropriate prophylactic and therapeutic standards. Many reports have explored the occurrence of bacteremia after dental procedures, but the results have been conflicting.

Collagen-binding proteins of Streptococcus mutans and related streptococci

The ability of Streptococcus mutans to interact with collagen through the expression of collagen-binding proteins (CBPs) bestows this oral pathogen with an alternative to the sucrose-dependent mechanism of colonization classically attributed to caries development. Based on the abundance and distribution of collagen throughout the human body, stringent adherence to this molecule grants S. mutans with the opportunity to establish infection at different host sites. Surface proteins, such as SpaP, WapA, Cnm and Cbm, have been shown to bind collagen in vitro, and it has been suggested that these molecules play a role in colonization of oral and extra-oral tissues. However, robust collagen binding is not achieved by all strains of S. mutans, particularly those that lack Cnm or Cbm. These observations merit careful dissection of the contribution from these different CBPs towards tissue colonization and virulence. In this review, we will discuss the current understanding of mechanisms used by S. mutans and related streptococci to colonize collagenous tissues, and the possible contribution of CBPs to infections in different sites of the host.

Disease progression of acute pancreatitis in pediatric patients

BACKGROUND

Approximately 10% of patients with acute pancreatitis (AP) progress to chronic pancreatitis. Little is known about the factors that affect recurrence of pancreatitis after an initial episode. We retrospectively investigated patients with AP, focusing on their outcomes and the predictors for disease progression.

METHODS

Between July 2003 and June 2015, we retrospectively enrolled first-time AP patients with medical records on disease etiology, severity (according to the Atlanta classifications), and recurrence of AP. Independent predictors of recurrent AP (RAP) and chronic pancreatitis were identified using the logistic regression model.

RESULTS

Of the total 159 patients, 45 (28.3%) developed RAP, including two episodes of RAP in 19 patients, and 9 (5.7%) developed chronic pancreatitis. The median duration from the time of AP to the onset of RAP was 5.6 ± 2.3 months. RAP patients were identified as more common among patients with idiopathic first-time AP. The presence of severe ascites, pancreatic necrosis, and systemic complications was independent predictors of RAP in pediatric patients. Experiencing over two RAP episodes was the predictor for developing chronic pancreatitis. No influence of age or number of AP episodes was found on the occurrence of abdominal pain, pain severity, and the prevalence of any pain.

CONCLUSIONS

Severity of first-time AP and idiopathic first-time AP are related to RAP. Recurrence increases risk for progression to chronic pancreatitis. The risk of recurrence increased with increasing numbers of AP episodes.

Trends in incidence of infective endocarditis at the Medical Center of Alkmaar

INTRODUCTION

Infective endocarditis (IE) is a life-threatening illness with a high morbidity and mortality, and with a rise in incidence in patients with prosthetic valves and cardiac devices. Recently the Dutch guidelines of IE prophylaxis have been revised, limiting IE prophylaxis to the highest-risk population. The aim of the present study was to investigate the incidence of IE and its trend between 2008-2013 in a regional hospital in the Netherlands.

METHODS

This is an observational descriptive study of all patients who were admitted with IE to the Medical Center of Alkmaar (MCA) from 1 January 2008 to 31 December 2013.

RESULTS

A total of 89 patients with IE, including 7 patients (7.9 %) with a cardiac device IE (CDIE), were identified. In 2008 there were 8 patients with IE, this increased to 26 patients in 2013. Patients with a prosthetic valve IE increased from 25 % in 2008 to 34.6 % in 2013. This increase was not seen in patients with CDIE.

CONCLUSION

In the MCA we have observed an increase in patients with IE since 2010. This increase was in part attributable to prosthetic valve IE. A larger observational study is needed to investigate the increase of IE in the Netherlands.

Relapsing tricuspid valve endocarditis by multidrug-resistant Pseudomonas aeruginosa in 11 years: tricuspid valve replacement with an aortic valve homograft

Eleven years ago, a 27-year-old non-drug abuser woman was admitted to the hospital due to a burn injury. During the treatment, she was diagnosed with tricuspid valve infective endocarditis caused by multi-drug resistant (MDR) Pseudomonas aeruginosa (P. aeruginosa). She underwent tricuspid valve replacement (TVR) using a bioprosthetic valve, followed by 6 weeks of meropenem antibiotic therapy. Ten years later, she was again diagnosed with prosthetic valve infective endocarditis caused by MDR P. aeruginosa. She underwent redo-TVR with a bioprosthetic valve and was treated with colistin and ciprofloxacin. Ten months later, she was again diagnosed with prosthetic valve infective endocarditis with MDR P. aeruginosa as a pathogen. She underwent a second redo-TVR with a tissue valve and was treated with colistin. Two months later, her fever recurred and she was again diagnosed with prosthetic valve infective endocarditis caused by MDR P. aeruginosa. She eventually underwent a third redo-TVR using an aortic valve homograft and was discharged from the hospital after additional 6 weeks’ of antibiotic therapy. All the strains of P. aeruginosa isolated from each event of infective endocarditis were analyzed by repetitive deoxyribonucleic acid sequence-based polymerase chain reaction (rep-PCR) deoxyribonucleic acid (DNA) strain typing to determine the correlation of isolates. All of the pathogens in 11 years were similar enough to be classified as the same strain, and this is the first case report of TVR using an aortic valve homograft to treat relapsing endocarditis.

Antibiotic prophylaxis against infective endocarditis in adult and child patients. Knowledge among dentists in Saudi Arabia

OBJECTIVES

To evaluate dentists' knowledge regarding the prevention of infective endocarditis in Saudi Arabia and their implementation of the 2007 American Heart Association guidelines.

METHODS

In this cross-sectional study, in March 2014, 801 dentists who practice in different regions of Saudi Arabia completed a questionnaire regarding the need for antibiotic prophylaxis for specific cardiac conditions and specific dental procedures, prophylaxis regimens in adults and children, and recommendations for patients on chronic antibiotics, and in dental emergencies. The data were analyzed using one-way analyses of variance (ANOVAs) and independent t-tests, and a p-value less than 0.05 was considered statistically significant.

RESULTS

The total knowledge level regarding antibiotic prophylaxis among all participants was 52.2%, with a significant difference between dentists who graduated before and after 2007. Comparing the level of knowledge among different dental specialists, surgeons and periodontists had the highest level of knowledge regarding the use of antibiotic prophylaxis. Amoxicillin was prescribed as the drug of choice by 63.9% of the participants.

CONCLUSION

This study emphasized the need for continuous education and for formal inclusion of the guidelines in the students' curriculum, as well as for strategic placement of the guidelines in locations throughout dental clinics.

Coronary artery bypass grafting in a patient with pituitary adenoma: can alertness prevent tragedy?

Pituitary apoplexy is a rare, life-threatening complication that may occur after coronary artery bypass graft surgery for patients with pituitary adenomas. The dynamics of cardiopulmonary bypass may contribute to a sudden expansion of silent pituitary adenomas and result in the compression of surrounding structures. A range of clinical features have been described, and the condition requires prompt diagnosis and treatment to prevent further complications. Herein, we present an uncomplicated case highlighting the importance of diagnosing pituitary apoplexy, ensuring high alertness to the condition, so as to prevent life-threatening tragedy due to missed diagnosis.

Long-term clinical outcome of major adverse cardiac events in survivors of infective endocarditis: a nationwide population-based study

BACKGROUND

Substantial infective endocarditis (IE)-related morbidity and mortality may occur even after successful treatment. However, no previous study has explored long-term hard end points (ie, stroke, myocardial infarction, heart failure, cardiovascular death) in addition to all-cause mortality in IE survivors.

METHODS AND RESULTS

A nationwide population-based cohort study was conducted among IE survivors identified with the use of the Taiwan National Health Insurance Research Database during 2000 to 2009. IE survivors were defined as those who survived after discharge from first hospitalization with a diagnosis of IE. A total of 10 116 IE survivors were identified. IE survivors were matched to control subjects without IE at a 1:1 ratio through the use of propensity scores. The primary outcomes were stroke, myocardial infarction, readmission for heart failure, and sudden cardiac death or ventricular arrhythmia. The secondary outcomes were repeat IE and all-cause mortality. Compared with the matched cohort, IE survivors had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.59; 95% confidence interval [CI], 1.40-1.80), hemorrhagic stroke (aHR, 2.37; 95% CI, 1.90-2.96), myocardial infarction (aHR, 1.44; 95% CI, 1.17-1.79), readmission for heart failure (aHR, 2.24; 95% CI, 2.05-2.43), sudden death or ventricular arrhythmia (aHR, 1.69; 95% CI, 1.44-1.98), and all-cause death (aHR, 2.27; 95% CI, 2.14-2.40). Risk factors for repeat IE were older age, male sex, drug abuse, and valvular replacement after an initial episode of IE.

CONCLUSION

Despite treatment, the risk of long-term major adverse cardiac events was substantially increased in IE survivors.

Effect of statin therapy on mortality in patients with infective endocarditis

The aim of our study was to determine whether pre-emptive statin therapy was associated with improved outcome of infective endocarditis (IE). We conducted a nationwide, population-based, propensity score-matched cohort study with the Taiwan's National Health Insurance Research Database. All patients with IE between January 2000 and December 2010 were enrolled. The primary outcome was in-hospital mortality. The secondary outcome included all-cause mortality within the first 3 months, 6 months, and one year after the diagnosis of IE. Among 13,584 patients with IE, we applied propensity score-matching on a 1:4 ratio, in which 370 statin users were matched to 1,480 statin non-users. Compared with statin non-users, statin users had a significantly lower risk of in-hospital mortality (adjusted hazard ratio [aHR] 0.65, 95% confidence interval [CI], 0.49-0.86). The reduction in mortality from IE remained significant for follow-up 3 months (aHR 0.68, 95% CI, 0.53-0.88), 6 months (aHR 0.73, 95% CI, 0.58-0.91), and 12 months (aHR 0.68, 95% CI, 0.55-0.84). Statin therapy was associated with a reduced risk of ICU admission rates, shock events, the need for mechanical ventilation, but not significantly with the need for heart valvular replacement surgery. In conclusion, our study found that statin therapy is associated with a reduced risk of in-hospital and subsequent mortality of IE.

Repeat endocarditis: analysis of risk factors based on the International Collaboration on Endocarditis - Prospective Cohort Study

Repeat episodes of infective endocarditis (IE) can occur in patients who survive an initial episode. We analysed risk factors and 1-year mortality of patients with repeat IE. We considered 1874 patients enrolled in the International Collaboration on Endocarditis - Prospective Cohort Study between January 2000 and December 2006 (ICE-PCS) who had definite native or prosthetic valve IE and 1-year follow-up. Multivariable analysis was used to determine risk factors for repeat IE and 1-year mortality. Of 1874 patients, 1783 (95.2%) had single-episode IE and 91 (4.8%) had repeat IE: 74/91 (81%) with new infection and 17/91 (19%) with presumed relapse. On bivariate analysis, repeat IE was associated with haemodialysis (p 0.002), HIV (p 0.009), injection drug use (IDU) (p < 0.001), Staphylococcus aureus IE (p 0.003), healthcare acquisition (p 0.006) and previous IE before ICE enrolment (p 0.001). On adjusted analysis, independent risk factors were haemodialysis (OR, 2.5; 95% CI, 1.2-5.3), IDU (OR, 2.9; 95% CI, 1.6-5.4), previous IE (OR, 2.8; 95% CI, 1.5-5.1) and living in the North American region (OR, 1.9; 95% CI, 1.1-3.4). Patients with repeat IE had higher 1-year mortality than those with single-episode IE (p 0.003). Repeat IE is associated with IDU, previous IE and haemodialysis. Clinicians should be aware of these risk factors in order to recognize patients who are at risk of repeat IE.

Recurrent Prosthetic Mitral Valve Dehiscence due to Infective Endocarditis: Discussion of Possible Causes

Prosthetic valves are being widely used in the treatment of heart valve disease. Prosthetic valve endocarditis (PVE) is one of the most catastrophic complications seen in these patients. In particular, prosthetic valve dehiscence can lead to acute decompensation, pulmonary edema, and cardiogenic shock. Here, we discuss the medical management of late PVE in a patient with a prior history of late and redo early PVE and recurrent dehiscence. According to the present case, we can summarize the learning points as follows. A prior history of infective endocarditis increases the risk of relapse or recurrence, and these patients should be evaluated very cautiously to prevent late complications. Adequate debridement of infected material is of paramount importance to prevent relapse. A history of dehiscence is associated with increased risk of relapse and recurrent dehiscence.

DNA persistence and relapses questions on the treatment strategies of Enterococcus infections of prosthetic valves

We used amplification of the 16S rRNA gene followed by sequencing to evaluate the persistence of bacterial DNA in explanted heart valve tissue as part of the routine work of a clinical microbiology laboratory, and we analyzed the role of this persistence in the relapses observed in our center. We enrolled 286 patients treated for infective endocarditis (IE) who had valve replacement surgery and were diagnosed according to the modified Duke's criteria described by Li et al. from a total of 579 IE cases treated in our center. The patients were grouped based on the infecting bacteria, and we considered the 4 most common bacterial genus associated with IE separately (144 were caused by Streptococcus spp., 52 by Enterococcus spp., 58 by Staphylococcus aureus and 32 by coagulase-negative Staphylococcus). Based on our cohort, the risk of relapse in patients with enterococcal prosthetic valve infections treated with antibiotics alone was 11%. Bacterial DNA is cleared over time, but this might be a very slow process, especially with Enterococcus spp. Based on a comprehensive review of the literature performed on Medline, most reports still advise combined treatment with penicillin and an aminoglycoside for as long as 4-6 weeks, but there has been no consensus for the treatment of enterococcal infection of prostheses in IE patients.

Excess mortality and morbidity in patients surviving infective endocarditis

BACKGROUND

Mortality and morbidity associated with infective endocarditis may extend beyond successful treatment. The primary objective was to analyze rates, temporal changes, and predictors of excess mortality in patients surviving the acute phase of endocarditis. The secondary objective was to determine the rate of recurrence and the need for late cardiac surgery.

METHODS

An observational cohort study was conducted at a university-affiliated tertiary medical center, among 328 patients who survived the active phase of endocarditis. We used age-, sex-, and calendar year-specific mortality hazard rates of the Bouches-du-Rhone French district population to calculate expected survival and excess mortality. The risk of recurrence and late valve surgery was also assessed.

RESULT

Compared with expected survival, patients surviving a first episode of endocarditis had significantly worse outcomes (P = .001). The relative survival rates at 1, 3, and 5 years were 92% (95% CI, 88%-95%), 86% (95% CI, 77%-92%), and 82% (95% CI, 59%-91%), respectively. This excess mortality was observed during the entire follow-up period but was the highest during the first year after hospital discharge. Most of the recurrences and late cardiac surgeries also occurred during this period. Women exhibited a higher risk of age-adjusted excess mortality (adjusted excess hazard ratio, 2.0; 95% CI, 1.05-3.82; P = .03). Comorbidity index, recurrence of endocarditis, and history of an aortic valve endocarditis in women were independent predictors of excess mortality.

CONCLUSIONS

These results justify close monitoring of patients after successful treatment of endocarditis, at least during the first year. Special attention should be paid to women with aortic valve damage.

A Case of Escherichia coli Endocarditis After Hemorrhoidectomy Performed by a Herbalist

We describe the first reported case of Escherichia coli endocarditis following a hemorrhoidectomy that was performed by the patient's herbalist. With increasing frequency, patients are seeking care by those who practice alternative medicine. Physicians must become more aware of the impact and possible complications related to this practice. Prosthetic valve endocarditis ranges up to 1.5% per patient-year for mechanical mitral valves and up to 0.1% per patient-year for other valves. Although the incidence of aortic prosthetic valve endocarditis is not uncommon, the concomitant organism and its mode of bacteremia make this a most unusual case. There is a paucity of information in the literature regarding surgical complications performed by alternative medicine practitioners. To our knowledge, a case of gram-negative endocarditis as a result of hemorrhoidectomy performed by an herbalist has never been reported.

Vancomycin AUC24/MIC ratio in patients with complicated bacteremia and infective endocarditis due to methicillin-resistant Staphylococcus aureus and its association with attributable mortality during hospitalization

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of complicated bacteremia (CB) and infective endocarditis (IE). The gold standard treatment for these infections is vancomycin. A vancomycin area under the concentration-time curve from 0 to 24 h (AUC(24))/MIC ratio of >400 has been suggested as a target to achieve clinical effectiveness, and yet to date no study has quantitatively investigated the AUC(24)/MIC ratio and its association with attributable mortality (AM). We performed a review of patients treated for MRSA CB and IE from 1 July 2006 to 30 June 2008. AM was defined as deaths where CB or IE was documented as the main cause or was mentioned as the main diagnosis. Classification and regression tree analysis (CART) was used to identify the AUC(24)/MIC ratio associated with AM. Mann-Whitney and Fisher exact tests were used for univariate analysis, and logistic regression was used for multivariate modeling. The MICs were determined by Etest, and the AUC(24) was determined using a maximum a posteriori probability-Bayesian estimator. A total of 32 CB and 18 IE patients were enrolled. The overall crude mortality and AM were 24 and 16%, respectively. The CART-derived partition for the AUC(24)/MIC ratio and AM was <211. Patients with an AUC(24)/MIC ratio of <211 had a >4-fold increase in AM than patients who received vancomycin doses that achieved an AUC(24)/MIC ratio of ≥211 (38 and 8%, respectively; P = 0.02). In bivariate analysis the APACHE-II score and an AUC(24)/MIC ratio of <211 were significantly associated with AM. In the multivariate model, the APACHE-II score (odds ratio, 1.24; P = 0.04) and a vancomycin AUC/MIC ratio of <211 (odds ratio, 10.4; P = 0.01) were independent predictors of AM. In our analysis, independent predictors of AM were the APACHE-II score and an AUC(24)/MIC ratio of <211. We believe further investigations are warranted.

Surgery in current therapy for infective endocarditis

The introduction of the Duke criteria and transesophageal echocardiography has improved early recognition of infective endocarditis but patients are still at high risk for severe morbidity or death. Whether an exclusively antibiotic regimen is superior to surgical intervention is subject to ongoing debate. Current guidelines indicate when surgery is the preferred treatment, but decisions are often based on physician preferences. Surgery has shown to decrease the risk of short-term mortality in patients who present with specific symptoms or microorganisms; nevertheless even then it often remains unclear when surgery should be performed. In this review we i) systematically reviewed the current literature comparing medical to surgical therapy to evaluate if surgery is the preferred option, ii) performed a meta-analysis of studies reporting propensity matched analyses, and iii), briefly summarized the current indications for surgery.

[Infective endocarditis: the role of surgery]

Infective endocarditis (IE) is a serious disease which can carry a bad prognosis if it is not appropriately treated. Sometimes the clinical evolution is unfavourable despite an optimal medical therapy with antibiotics. Surgery in these cases has an important role to eliminate the source of infection or to perform a valve replacement. The surprising evolution of patients operated in critic circumstances take us to analyze the role of early surgery. As physicians, we need to know these patients' risks and to establish the adequate surgical indications.