Multidisciplinary Teams for the Management of Infective Endocarditis: A Systematic Review and Meta-analysis

An aortic root abscess mimic identified by multi-disciplinary imaging review: a case report

Background

While echocardiography and cardiac positron emission tomography (PET) can aid in the diagnosis of prosthetic valve endocarditis (PVE), post-operative changes can lead to false-positive imaging findings. We report a case of a patient with an aortic valve prosthesis with remnant BioGlue deposits mimicking a para-valvular abscess on imaging in the setting of suspected PVE.

Case summary

A 67-year-old man presented with 2 days of fever, chills, and altered mentation. He had a history of two prior aortic root replacements-19 and 4 years prior to his presentation. He had blood cultures that were persistently positive for Pseudomonas aeruginosa. Initial transoesophageal echocardiogram (TEE) was notable for a thickening of the posterior aortic root thought to be consistent with post-surgical changes. Cardiac PET showed significant uptake around the prosthetic aortic valve, concerning for a para-valvular abscess. However, given the patient's high risk for re-do surgery, clearance of blood cultures, and preserved valve function, our multi-disciplinary endocarditis team (MET) recommended non-surgical management and close follow-up. After 6 weeks of appropriate antibiotics, a TEE demonstrated concern for an evolving para-valvular abscess. The MET performed extensive review of his prior surgical interventions and cardiac imaging, revealing the previous use of surgical BioGlue and stability in the aortic root on imaging, consistent with non-infectious post-surgical changes, and conservative management was recommended.

Discussion

Thorough review of prior interventions and serial imaging in patients with suspected PVE through a multi-disciplinary team approach is essential in elucidating the complete, often complex, clinical picture and recommending the most appropriate management.

[Standards in inpatient care of infectious diseases]

In addition to the one-year advanced training program in infectious diseases that has been in place for several years, a six-year-full specialist training in internal medicine and infectious diseases (ID) has recently been introduced in Germany. While recommendations for ID training program curricula were developed, there is no description of genuine ID activities in Germany, nor have any working standards been defined to date. However, this seems to be necessary, both for the structural implementation of ID in German hospitals and for ensuring the quality-of-care. The current article therefore outlines standards for core ID activities as well as quality requirements for efficient ID training programs. As long as no separate speciality for pediatric ID is established in Germany, these principles should also apply in paediatrics and adolescent medicine.

Etiological Aspects of Infectious Endocarditis in a Tertiary Hospital in Northeastern Romania

Background and Objectives: Infective endocarditis (IE) is a severe, life-threatening infection of the endocardial surface. Its incidence has shifted towards older, immunocompromised patients and those with cardiac devices. Materials and Methods: This study was conducted at the "Sf. Parascheva" Clinical Hospital of Infectious Diseases in Iasi, Romania, and retrospectively analyzed cases of IE from January 1, 2019, to September 30, 2024. It received ethical approval (Approval No. 7/17 June 2024). Results: The study included 130 patients with infectious endocarditis, predominantly men (75.38%), with a median age of 55 years. The most affected age groups were 50-59 and over 60 years, each representing 30.76% of cases. The most frequently implicated etiological agent was Staphylococcus aureus in 33% of cases. The most common antibiotic regimen combined glycopeptides and fluoroquinolones/polymyxins (27% cases). Conclusions: A multidisciplinary approach involving infectious disease specialists, cardiologists, and cardiovascular surgeons is essential for effective treatment. Immediate combined antibiotic therapy is vital for presumed IE cases. Despite advances in diagnosis and treatment, the high mortality rates highlight the importance of timely intervention. Future research should focus on improving preventive and therapeutic strategies for IE.

Impact of multidisciplinary Endocarditis Team on management of infective endocarditis

Infective Endocarditis (IE) is a complex, life-threatening disease. The aim of the present study was to evaluate the impact of the Endocarditis-Team on management of IE. This observational study conducted at a university hospital (2015‒22), included adult patients with IE. The study period was divided in two periods: before (pre-Endocarditis-Team; pre-ET) and after the establishment of the Endocarditis-Team (post-Endocarditis-Team; post-ET) on January 2018. Among 505 IE episodes (187 in pre-Endocarditis-Team, 318 in post-ET period), 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography was more commonly used in post-ET period (14 % vs. 28 %; p < 0.001). Overall, thirty-day and one-year mortality were 14 % and 27 %, respectively; no difference was observed between the two periods. In post-ET period, the administration of 4-weeks, rather than 6-weeks, of intravenous antimicrobial treatment was higher than in the post-ET period (15 % vs. 45 %; p < 0.001). Indication for surgery was present in 115 (61 %) patients in pre-ET and in 153 (48 %) in the post-ET period. In post-ET period, among patients with indication, valve surgery was more frequently performed (66 % vs. 78 %; p = 0.038). Such difference was due to a higher acceptance of operative indication by the cardiac surgeon (69 % vs. 94 %; p = 0.013). The observed increase in number of patients benefiting from cardiac surgery in the post-ET period led to a decrease of subsequent embolic events, since among patients with operative indication (n = 268), new embolic events after the establishment of the indication were more common in the pre-ET period compared to post-ET (23 % vs. 12 %; p = 0.033). After the implementation of the multidisciplinary Endocarditis-Team we observed several improvements in the general management of IE patients.

Endocarditis in Adult Congenital Heart Disease Patients: Prevention, Recognition, and Management

PURPOSE OF REVIEW

Present an updated overview of the prevention, diagnosis, and management of infective endocarditis in adult patients with congenital heart disease.

RECENT FINDINGS

Care for patients with infective endocarditis is changing in the areas of specialized teams, diagnostics, and prevention. Endocarditis teams should be involved in the care of ACHD patients. The 2023 Duke Criteria for Infective Endocarditis and the 2023 European Society of Cardiology Guidelines have updated the criteria for diagnosis including new major criteria such as CT and positron emission computed tomography with 18F-fluorodeoxyglucose (FDG) scans. Immunological, PCR, and nucleic acid-based tests are now acceptable means to isolate infective organisms. Clindamycin is no longer recommended for antibiotic prophylaxis due to resistance and side effect profile. Special considerations for antibiotic prophylaxis and management must be made for specific congenital heart diseases in adulthood and pregnant ACHD patients. Infective endocarditis (IE), a potentially devastating clinical entity, is a feared threat to the health of adults with congenital heart disease (ACHD). IE needs a systematic approach for its prevention, early diagnosis and management with a multidisciplinary IE team's involvement. There have been changes in the diagnostics and management of IE, which is reflected in updated diagnostic criteria. Timely blood cultures and imaging continue to be the mainstay of diagnosis, however the timing of blood cultures, microbiological testing, and types of diagnostic imaging such as the positron emission computed tomography with 18F-fluorodeoxyglucose (FDG) scan are new. Bicuspid aortic valves, ventricular septal defects, transcatheter pulmonary valve replacements, and tetralogy of Fallot are diagnoses at higher risk for IE in the ACHD population. The following article will focus on the preventive strategies, in addition to novel diagnostic and therapeutic approaches of IE in ACHD patients.

Epidemiology and treatment of invasive Bartonella spp. infections in the United States

OBJECTIVES

Bartonella spp., renowned for cat-scratch disease, has limited reports of dissemination. Tissue and blood cultures have limitations in detecting this fastidious pathogen. Molecular testing (polymerase chain reaction, PCR) and cell-free DNA have provided an avenue for diagnoses. This retrospective observational multicenter study describes the incidence of disseminated Bartonella spp. and treatment-related outcomes.

METHODS

Inclusion criteria were diagnosis of bartonellosis via diagnosis code, serology testing of blood, polymerase chain reaction (PCR) of blood, 16/18S tests of blood or tissue, cultures of blood or tissue, or cell-free DNA of blood or tissue from January 1, 2014, through September 1, 2021. Exclusions were patients who did not receive treatment, insufficient data on treatment course, absence of dissemination, or retinitis as dissemination.

RESULTS

Patients were primarily male (n = 25, 61.0%), white (n = 28, 68.3%), with mean age of 50 years (SD 14.4), and mean Charlson comorbidity index of 3.5 (SD 2.1). Diagnosis was primarily by serology (n = 34, 82.9%), with Bartonella henselae (n = 40, 97.6%) as the causative pathogen. Treatment was principally doxycycline with rifampin (n = 17, 41.5%). Treatment failure occurred in 16 (39.0%) patients, due to escalation of therapy during treatment (n = 5, 31.3%) or discontinuation of therapy due to an adverse event or tolerability (n = 5, 31.3%).

CONCLUSIONS

In conclusion, this is the largest United States-based cohort of disseminated Bartonella spp. infections to date with a reported 39% treatment failure. This adds to literature supporting obtaining multiple diagnostic tests when Bartonella is suspected and describes treatment options.

Surgical Therapy of Infective Prosthesis Endocarditis following TAVI: A Single Center's Experience

BACKGROUND/OBJECTIVES

Infective prosthesis endocarditis (IE) following transcatheter aortic valve implantation (TAVI) presents significant management challenges, marked by high mortality rates. This study reviews our center's experience with surgical interventions for IE in patients post-TAVI, focusing on outcomes, challenges, and procedural complexities, and providing an overview of the limited literature surrounding this subject.

METHODS

This study was executed as a comprehensive retrospective analysis, targeting the clinical outcomes of surgical treatment in patients presenting with PVE following TAVI procedures at our institution. From July 2017 to July 2022, we identified five patients who had previously undergone transfemoral transcatheter aortic valve implantation and were later diagnosed with PVE needing surgery, strictly adhering to the modified Duke criteria.

RESULTS

All surgical procedures were reported successful with no intra- or postoperative mortality. Patients were predominantly male (80%), with an average age of 76 ± 8.6 years, presenting mostly with dyspnea (NYHA Class II). The mean follow-up was between 121 and 1973 days, with outcomes showing no occurrences of stroke, myocardial infarction, or major bleeding. One patient expired from unrelated causes 3.7 years post-surgery. The operative and postoperative protocols demonstrated effective disease management with enhanced survival and minimal complications.

CONCLUSIONS

The surgical treatment of IE following TAVI, though challenging, can be successfully achieved with careful patient selection and a multidisciplinary approach. The favorable outcomes suggest that surgical intervention remains a viable option for managing this high-risk patient group. Our study also highlights the scarce literature available on this topic, suggesting an urgent need for more comprehensive research to enhance understanding and improve treatment strategies. Future studies with larger cohorts are needed to further validate these findings and refine surgical strategies for this growing patient population.

Recent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4

This focused review highlights the latest issues in native valve infective endocarditis. Native valve disease moderately increases the risk of developing infective endocarditis. In 2023, new diagnostic criteria were published by the Duke-International Society of Cardiovascular Infectious Diseases group. New pathogens were designated as typical, and findings on computed tomography imaging were included as diagnostic criteria. It is now recognized that a multidisciplinary approach to care is vital, and the role of an "endocarditis team" is highlighted. Recent studies have suggested that a transition from intravenous to oral antibiotics in selected patients may be reasonable, and the role of long-acting antibiotics is discussed. It is also now clear that an aggressive surgical approach can be life-saving in some patients. Finally, results of several recent studies have suggested there is an association between dental and other invasive procedures and an increased risk of developing infective endocarditis. Moreover, data indicate that antibiotic prophylaxis may be effective in some scenarios.

Cryptogenic Stroke Complicated by Infective Endocarditis: Exploring the Multidisciplinary Interplay

Infective endocarditis (IE) poses a significant clinical challenge due to its non-specific symptoms and variety of complications. Complications can include ischaemic stroke, valve dysfunction, discitis, and osteomyelitis, highlighting the complexity of IE management. We present a case of a male in his 40s, admitted with an ischaemic stroke, eventually being found to have underlying IE with a plethora of complications. This case highlights the importance of collaboration among specialists to form a multidisciplinary team, which is essential for the effective delivery of care. Furthermore, there is a critical need to explore the psychological impact of IE on patient outcomes, advocating for a holistic approach that considers psychological well-being alongside medical management. Future research should address these underexplored facets to improve patient care and outcomes in IE.

Acute drug-use-related native tricuspid valve infective endocarditis: a non-surgical disease

As a result of the ongoing opioid epidemic, physicians have encountered increasing rates of drug-use-related native tricuspid valve infective endocarditis (DU-TVIE), a complex multi-faceted disease that is best managed by interdisciplinary teams. Despite the large number of patients with DU-TVIE, there is little data to support the optimal treatment strategy with respect to medical and surgical therapy. The recent introduction of percutaneous mechanical aspiration of tricuspid valve vegetations has added another treatment modality that is also of uncertain benefit. Here we review the literature on the management of DU-TVIE and highlight the multi-step treatment approach developed by the multidisciplinary endocarditis team at the University of Kentucky.