Immediate and long-term outcome of left-sided infective endocarditis. A 12-year prospective study from a contemporary cohort in a referral hospital

Infective endocarditis

First described more than 350 years ago, infective endocarditis represents a global health concern characterised by infections affecting the native or prosthetic heart valves, the mural endocardium, a septal defect, or an indwelling cardiac device. Over recent decades, shifts in causation and epidemiology have been observed. Echocardiography remains pivotal in the diagnosis of infective endocarditis, with alternative imaging modalities gaining significance. Multidisciplinary management requiring expertise of cardiologists, cardiovascular surgeons, infectious disease specialists, microbiologists, radiologists and neurologists, is imperative. Current recommendations for clinical management often rely on observational studies, given the limited number of well conducted randomised controlled trials studying infective endocarditis due to the rarity of the disease. In this Seminar, we provide a comprehensive overview of optimal clinical practices in infective endocarditis, highlighting key aspects of pathophysiology, pathogens, diagnosis, management, prevention, and multidisciplinary approaches, providing updates on recent research findings and addressing remaining controversies in diagnostic accuracy, prevention strategies, and optimal treatment.

AKI development is an independent predictor of mortality in infective endocarditis

INTRODUCTION

Infective endocarditis presents a 25% mortality. Acute kidney injury (AKI) develops in up to 70% of the cases. The aim of this study is to evaluate the predictive value of AKI in mortality due to endocarditis and to assess its associated factors.

METHODS

Unicentric and retrospective study including all patients with in-hospital diagnosis of endocarditis between 2015 and 2021. Epidemiological data and comorbidities were collected at baseline. During admission, renal function parameters, infection-related variables and mortality were collected. Using adjusted multivariate models, LRA predictive value was determined.

RESULTS

One hundred and thirty-four patients (63% males, age 72±15 years) were included. Of them 94 (70%) developed AKI (50% AKIN-1, 29% AKIN-2 and 21% AKIN-3). Factors associated to AKI were age (p=0.03), hypertension (p=0.005), previous chronic kidney disease (p=0.001), heart failure (p=0.006), peripheral vascular disease (p=0.022) and glomerular filtration rate (GFR) at baseline (p<0.001). GFR at baseline was the only factor independently associated to AKI (OR 0.94, p=0.001). In-hospital deaths were registered in 46 (34%) patients. Of them, 45 (98%) patients had developed AKI. AKI was independently associated to mortality through diverse multivariate models. GFR loss (OR 1.054, p<0.001) and GFR at baseline (0.963, p=0.012) also predicted mortality during admission.

CONCLUSIONS

AKI development and its severity (GFR loss and AKIN severity) impacts in in-hospital mortality due to infective endocarditis.

Suppressive antibiotic therapy for infectious endocarditis

OBJECTIVES

Suppressive antibiotic therapy (SAT) is a long-term antibiotic strategy at times applied when an indicated surgical management of infective endocarditis (IE) is not possible. Our aim was to describe the characteristics and outcomes of patients having received SAT for IE.

METHODS

We conducted a retrospective, observational study at Strasbourg University Hospital, France between January 2020 and May 2023. We reviewed all medical files taken into consideration at weekly meetings of the local Multidisciplinary Endocarditis Team (MET) during the study period. We included patients having received SAT following the MET evaluation. The primary endpoint was all-cause mortality at most recent follow-up. Secondary endpoints included all-cause mortality at 3 and 6 months, infection relapse, and tolerance issues attributed to SAT.

RESULTS

The MET considered 251 patients during the study time, among whom 22 (9 %) had received SAT. Mean age was 77.2 ± 12.3 years. Patients were highly comorbid with a mean Charlson index score of 6.6 ± 2.5. Main indication for SAT was surgery indicated but not performed or an infected device not removed (20/22). Fourteen patients had prosthetic valve IE, including 9 TAVIs. Six patients had IE affecting cardiac implantable electronic devices. Staphylococcus aureus and enterococci were the main bacteria involved (6/22 each). Median follow-up time was 249 days (IQR 95-457 days). Mortality at most recent follow-up was 23 % (5/22). Three patients (14 %) presented tolerance issues attributed to SAT, and two patients suffered late infectious relapse.

CONCLUSION

Mortality at most recent follow-up was low and tolerance issues were rare for patients under SAT, which might be a palliative approach to consider when optimal surgery or device removal is not possible.

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.

Vegetation Formation in Staphylococcus Aureus Endocarditis Inversely Correlates With RNAIII and sarA Expression in Invasive Clonal Complex 5 Isolates

Infective endocarditis (IE) is one of the most feared and lethal diseases caused by Staphylococcus aureus. Once established, the infection is fast-progressing and tissue destructive. S. aureus of the clonal complex 5 (CC5) commonly cause IE yet are severely understudied. IE results from bacterial colonization and formation of tissue biofilms (known as vegetations) on injured or inflamed cardiac endothelium. S. aureus IE is promoted by adhesins, coagulases, and superantigens, with the exotoxins and exoenzymes likely contributing to tissue destruction and dissemination. Expression of the large repertoire of virulence factors required for IE and sequelae is controlled by complex regulatory networks. We investigated the temporal expression of the global regulators agr (RNAIII), rot, sarS, sarA, sigB, and mgrA in 8 invasive CC5 isolates and established intrinsic expression patterns associated with IE outcomes. We show that vegetation formation, as tested in the rabbit model of IE, inversely correlates with RNAIII and sarA expression during growth in Todd-Hewitt broth (TH). Large vegetations with severe sequelae arise from strains with high-level expression of colonization factors but slower transition towards expression of the exotoxins. Overall, strains proficient in vegetation formation, a hallmark of IE, exhibit lower expression of RNAIII and sarA. Simultaneous high expression of RNAIII, sarA, sigB, and mgrA is the one phenotype assessed in this study that fails to promote IE. Thus, RNAIII and sarA expression that provides for rheostat control of colonization and virulence genes, rather than an on and off switch, promote both vegetation formation and lethal sepsis.

Infective Endocarditis: Still More Challenges Than Convictions

After fourteen decades of medical and technological evolution, infective endocarditis continues to challenge physicians in its daily diagnosis and management. Its increasing incidence, demographic shifts (affecting older patients), microbiology with higher rates of Staphylococcus infection, still frequent serious complications and substantial mortality make endocarditis a very complex disease. Despite this, innovations in the diagnosis, involving microbiology and imaging, and improvements in intensive care and cardiac surgical techniques, materials and timing can impact the prognosis of this disease. Ongoing challenges persist, including rethinking prophylaxis, improving the diagnosis criteria comprising blood culture-negative endocarditis and prosthetic valve endocarditis, timing of surgical intervention, and whether to perform surgery in the presence of ischemic stroke or in intravenous drug users. A combined strategy on infective endocarditis is crucial, involving advanced clinical decisions and protocols, a multidisciplinary approach, national healthcare organization and health policies to achieve better results for our patients.

Infective endocarditis treated in a secondary hospital: epidemiological, clinical, microbiological characteristics and prognosis, with special reference to patients transferred to a third level hospital

OBJECTIVE

To analyse the clinical and epidemiological characteristics and mortality-related factors of patients admitted to a secondary hospital with Infective Endocarditis (IE).

METHODS

Observational study of a cohort of patients who have been diagnosed with IE in a secondary hospital and evaluated in accordance with a pre-established protocol.

RESULTS

A total of 101 cases were evaluated (years 2000-2017), with an average age of 64 years and a male-to-female ratio of 2:1. 76% of the cases had an age-adjusted Charlson comorbidity index of >6, with 21% having had a dental procedure and 36% with a history of heart valve disease. The most common microorganism was methicillin-susceptible S. aureus (36%), with bacterial focus of unknown origin in 54%. The diagnostic delay time was 12 days in patients who were transferred, compared to 8 days in patients who were not transferred (p=0.07); the median surgery indication delay time was 5 days (IQR 13.5). The in-hospital mortality rate was 34.6% and the prognostic factors independently associated with mortality were: cerebrovascular events (OR 98.7%, 95% CI, 70.9-164.4); heart failure (OR 27.3, 95% CI, 10.2-149.1); and unsuitable antibiotic treatment (OR 7.2, 95% CI, 1.5-10.5). The mortality rate of the patients who were transferred and who therefore underwent surgery was 20% (5/25).

CONCLUSIONS

The onset of cerebrovascular events, heart failure and unsuitable antibiotic treatment are independently and significantly associated with in-hospital mortality. The mortality rate was higher than the published average (35%); the diagnostic delay was greater in patients for whom surgery was indicated.

Predictors of long-term mortality in left-sided infective endocarditis: an historical cohort study in 414 patients

INTRODUCTION

Very limited data are available on the long-term outcome of infective endocarditis (IE) and its determinants. The aim of this study was to identify the predictors of long-term mortality in patients affected by left sided IE (LSIE).

METHODS

This was an historical retrospective observational study on prospectively collected data from patients with LSIE hospitalized in our Unit (January 2000-December 2017). Multiple variables relevant to history, physical examination, laboratory tests, echocardiography, comorbidities, complications and outcome were analysed by Cox regression to identify predictors of long-term mortality.

RESULTS

414 patients were included, and followed up for a median of 39 months [IQR 11-74]. Median age was 59 years [range 3-89], and most patients were male. Over 50% showed at least one comorbidity. Hyperglycaemia, increased creatinine and an indication for surgery predicted in-hospital mortality, while a prior myocardial infarction, chronic kidney disease (CKD) on hemodialysis and a larger vegetation were independent predictors of 1-year mortality. At multivariate analysis, peripheral arterial disease (p= 0.017), hyperglycemia on admission (p=0.013) and a higher BMI (p=0.009) were independent predictors of long-term mortality in 1-year survivors. At multivariable Cox proportional hazard regression, peripheral arterial disease (p=0.002), hyperglycemia (p=0.041) and CKD on hemodialysis (p=0.025) confirmed to be independently associated with an increased risk of long-term mortality in the overall 414 patient cohort.

CONCLUSIONS

Cardiovascular and metabolic risk signals, specifically peripheral arterial disease and hyperglicemia, affect long-term mortality of LSIE. An active and long-term follow up seems warranted in IE survivors showing these conditions at outset.

Time to abandon ampicillin plus gentamicin in favour of ampicillin plus ceftriaxone in Enterococcus faecalis infective endocarditis? A meta-analysis of comparative trials

Background

Current guidelines recommend either ampicillin plus ceftriaxone (AC) or amoxicillin/ampicillin plus gentamicin (AG) with an equivalent class IB recommendation in Enterococcus faecalis endocarditis. However, previous observational studies suggest that AC might be favourable in terms of adverse events.

Objectives

To investigate whether AC is non-inferior to AG, and if it is associated with less adverse events.

Methods

In June 2021, a systematic literature search using the databases PubMed/MEDLINE, CDSR, CENTRAL, CCAs, EBM Reviews, Web of Science and LILACS was conducted by two independent reviewers. Studies were considered eligible if (P) patients included were ≥ 18 years of age and had IE with E. faecalis, (I) treatment with AC was compared to (C) treatment with AG and (O) outcomes on in-hospital mortality, nephrotoxicity and adverse events requiring drug withdrawal were reported. Odds ratios and 95% confidence intervals were calculated using random-effects models with the Mantel–Haenszel method, the Sidik–Jonkman estimator for τ² and the Hartung–Knapp adjustment.

Results

Treatment with AC was non-inferior to AG, as depicted by no significant differences in-hospital mortality, 3-month mortality, relapses or treatment failure. Furthermore, AC was associated with a lower prevalence of nephrotoxicity (OR 0.45 [0.26–0.77], p = 0.0182) and drug withdrawal due to adverse events (OR 0.11 [0.03–0.46], p = 0.0160) than AG.

Conclusions

Treatment with AC was non-inferior to treatment with AG, and it was associated with a reduced prevalence of nephrotoxicity and drug withdrawal due to adverse events. Thus, combination therapy with AC appears favourable over AG in patients with E. faecalis IE.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01971-3.

Importance of In-Hospital Prospective Registry and Infectious Endocarditis Heart Team to Monitor and Improve Quality of Care in Patients with Infectious Endocarditis

Aim: To investigate the value of prospective in-hospital registry data and the impact of an infectious endocarditis heart team approach (IEHT) on improvement in quality of care and monitor outcomes in hospitalized patients with IE. Methods: Between December 2014 and the end of 2019, 160 patients were hospitalized in one centre with the definite diagnosis of infectious endocarditis (IE) and entered in a prospective registry. From 2017, an IEHT was introduced. Propensity score matching was used to assess the impact of an IEHT approach on clinical outcomes. Results: Median age was 72.5 y (62.75–80.00), diabetes was present in 33.1%, chronic kidney disease in 27.5%, COPD in 17.5%, and a history of ischaemic heart disease in 30.6%. Prosthetic valve IE was observed in 43.8% and device-related IE in 16.9% of patients. Staphylococcus (37.5%) was the most frequent pathogen followed by streptococcus (24.4%) and enterococcus (23.1%). Overall, 30-day and 1-year mortality were 19.4% and 37.5%, respectively. The introduction of prospective data collection and IE heart team was associated with a trend towards reduction of adjusted 1-year mortality (26.5% IEHT vs. 41.2% controls, p = 0.0699). An IEHT clinical decision-making approach was independently associated with a shorter length of stay (p = 0.04). Conclusions: Use of a prospective registry of IE coupled with a heart team approach was associated with more efficient patient management and a trend towards lower mortality. Prospective data collection and dedicated IEHT have the potential to improve patient care and clinical outcomes.

Prognostic value of D-dimer for adverse outcomes in patients with infective endocarditis: an observational study

BACKGROUND

Increased D-dimer levels have been shown to correlate with adverse outcomes in various clinical conditions. However, few studies with a large sample size have been performed thus far to evaluate the prognostic value of D-dimer in patients with infective endocarditis (IE).

METHODS

613 patients with IE were included in the study and categorized into two groups according to the cut-off of D-dimer determined by receiver operating characteristic (ROC) curve analysis for in-hospital death: > 3.5 mg/L (n = 89) and ≤ 3.5 mg/L (n = 524). Multivariable regression analysis was used to determine the association of D-dimer with in-hospital adverse events and six-month death.

RESULTS

In-hospital death (22.5% vs. 7.3%), embolism (33.7% vs 18.2%), and stroke (29.2% vs 15.8%) were significantly higher in patients with D-dimer > 3.5 mg/L than in those with D-dimer ≤ 3.5 mg/L. Multivariable analysis showed that D-dimer was an independent risk factor for in-hospital adverse events (odds ratio = 1.11, 95% CI 1.03-1.19, P = 0.005). In addition, the Kaplan-Meier curve showed that the cumulative 6-month mortality was significantly higher in patients with D-dimer > 3.5 mg/L than in those with D-dimer ≤ 3.5 mg/L (log-rank test = 39.19, P < 0.0001). Multivariable Cox regression analysis showed that D-dimer remained a significant predictor for six-month death (HR 1.11, 95% CI 1.05-1.18, P < 0.001).

CONCLUSIONS

D-dimer is a reliable prognostic biomarker that independently associated with in-hospital adverse events and six-month mortality in patients with IE.

Long-term antibiotic therapy in patients with surgery-indicated not undergoing surgery infective endocarditis

BACKGROUND

To date, there is little information regarding management of patients with infective endocarditis (IE) that did not undergo an indicated surgery. Therefore, we aimed to evaluate prognosis of these patients treated with a long-term antibiotic treatment strategy, including oral long term suppressive antibiotic treatment in five referral centres with a multidisciplinary endocarditis team.

METHODS

This retrospective, multicenter study retrieved individual patient-level data from five referral centres in Spain. Among a total of 1797, 32 consecutive patients with IE were examined (median age 72 years; 78% males) who had not undergone an indicated surgery, but received long-term antibiotic treatment (LTAT) and were followed by a multidisciplinary endocarditis team, between 2011 and 2019. Primary outcomes were infection relapse and mortality during follow-up.

RESULTS

Among 32 patients, 21 had IE associated with prostheses. Of the latter, 8 had an ascending aorta prosthetic graft. In 24 patients, a switch to long-term oral suppressive antibiotic treatment (LOSAT) was considered. The median duration of LOSAT was 277 days. Four patients experienced a relapse during follow-up. One patient died within 60 days, and 12 patients died between 60 days and 3 years. However, only 4 deaths were related to IE.

CONCLUSIONS

The present study results suggest that a LTAT strategy, including LOSAT, might be considered for patients with IE that cannot undergo an indicated surgery. After hospitalization, they should be followed by a multidisciplinary endocarditis team.

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.

Increased glucose variability is associated with major adverse events in patients with infective endocarditis undergo surgical treatment

Background

This study aimed to investigate the prognostic value of glucose variability (GV) in predicting postoperative major adverse events (MAEs) in patients with infective endocarditis (IE) who underwent surgical treatment.

Methods

This retrospective observational study included a total of 381 consecutive patients who underwent surgical treatment in our institution from October 2007 to August 2019. The MAEs included all-cause death, stroke, myocardial infarction, acute heart failure, IE recurrence, acute renal failure and sepsis. Postoperative GV in the first 24 hours was measured by the mean 24-hour glucose, standard deviation, coefficient of variation (CV) and mean amplitude of glycemic excursions. Univariate and multivariate logistic regression analyses were performed to identify the independent association of GV with MAEs.

Results

Of the 381 patients, 79 (20.7%) developed MAEs. The 30-day mortality of the overall study cohort was 5.23%. The multivariate logistic regression analysis indicated that 24-hour GV, measured as the CV [odds ratio (OR) =1.49, 95% CI, 1.23–3.57, P=0.012], was significantly associated with MAEs in IE patients. For every 10% increase in 24‐hour CV, there was a 49% increase in the risk of MAEs. Furthermore, compared to patients in the low tertile of GV, patients in the top tertile of 24-hour GV had a higher 30-day mortality and an increased incidence of heart failure and hemodialysis as well as longer ventilation support.

Conclusions

The results of this retrospective investigation demonstrated that increased GV measured by CV is an independent predictor of postoperative MAEs in patients undergoing surgical treatment for IE.

Differences in mortality in patients undergoing surgery for infective endocarditis according to age and valvular surgery

Background

Infective endocarditis (IE) is associated with high mortality. Surgery may improve survival and reduce complications, but the balance between benefit and harm is difficult and may be closely related to age and type of surgical intervention. We aimed to examine how age and type of left-sided surgical intervention modified mortality in patients undergoing surgery for IE.

Methods

By crosslinking nationwide Danish registries we identified patients with first-time IE undergoing surgical treatment 2000–2017. Patients were grouped by age < 60 years, 60–75 years, and ≥ 75 years. Multivariable adjusted Cox proportional hazard analysis was used to examine factors associated with 90-day mortality.

Results

We included 1767 patients with IE undergoing surgery, 735 patients < 60 years (24.1% female), 766 patients 60–75 years (25.8% female), and 266 patients ≥75 years (36.1% female). The proportions of patients undergoing surgery were 35.3, 26.9, and 9.1% for patients < 60 years, 60–75 years, and > 75 years, respectively. Mortality at 90 days were 7.5, 13.9, and 22.3% (p < 0.001) for three age groups. In adjusted analyses, patients 60–75 years and patients ≥75 years were associated with a higher mortality, HR = 1.84 (95% CI: 1.48–2.29) and HR = 2.47 (95% CI: 1.88–3.24) as compared with patients < 60 years. Factors associated with 90-day mortality were: mitral valve surgery, a combination of mitral and aortic valve surgery as compared with isolated aortic valve surgery, age, diabetes, and prosthetic heart valve implantation prior to IE admission.

Conclusions

In patients undergoing surgery for IE, mortality increased significantly with age and 1 in 5 died above age 75 years. Mitral valve surgery as well as multiple valve interventions augmented mortality further.

Impact of referral bias on prognostic studies outcomes: insights from a population-based cohort study on infective endocarditis

PURPOSE

Prognostic studies derived from samples of patients managed in tertiary hospitals are subject to referral bias. We aimed to characterize this bias using the example of infective endocarditis.

METHODS

We analyzed data from a French population-based cohort, which included 497 patients with infective endocarditis. Patients were admitted directly to a tertiary hospital (Group T), admitted to a non-tertiary hospital and referred to a tertiary hospital (Group NTT) or not (Group NT). We compared patients' characteristics, survival rates and prognostic factors between groups.

RESULTS

Compared with Group T (n = 291), NTT patients (n = 144) were more often males (81.3% vs. 72.5%; P = .046), injection drug users (9.7% vs. 4.5%; P = .033), and had more frequent surgical indications (78.5% vs. 64.3%; P = .003). Compared with Group NT (n = 62), NTT patients were more often males (81.3% vs. 67.7%; P = .034) and had surgical indications more often (78.5% vs. 19.4%; P < .001). One-year survival was higher in NTT + T patients than in NT patients (73.0% vs. 56.1%; P = .01). Prognostic factors and hazard ratios estimates varied across groups.

CONCLUSIONS

When derived from samples mixing patients admitted directly and those referred to tertiary hospitals, validity of characteristics description, survival estimates, and hazard ratios is threatened by referral bias.

The epidemiology of infective endocarditis with focus on non-device related right-sided infective endocarditis: A retrospective register-based study in the region of Southern Denmark

AIMS

Non-device related right-sided infective endocarditis (ND-RSIE) is not well characterized. We aimed to characterize patients with infective endocarditis (IE) with emphasis on the epidemiology, clinical characteristics and complications of ND-RSIE.

METHODS

In this population-based cohort study, we identified patients with IE using ICD-10 codes from the Danish National Hospital Register in the Region of Southern Denmark between January 2007 and May 2017. Hospital records were reviewed, and characteristics and outcomes recorded.

RESULTS

We included 1243 confirmed IE episodes of which 82% were left-sided IE, 11% were cardiac device right sided infective endocarditis (RSIE) and 7% were ND-RSIE. Patients with ND-RSIE were considerably younger, had less comorbidity and had a lower 30-day mortality (6%) compared with patients with device RSIE (24%) and left-sided IE (26%) (p<0.01). ND-RSIE was associated with underlying heart disease, involvement of the tricuspid valve (57%), Staphylococcus species (53%) and complications (61%). Forty percent of ND-RSIE occurred among people who inject drugs (PWID) for whom significant differences were observed compared with non-PWID with regards to tricuspid valve involvement (96% vs. 32%), causative microorganisms (Staphylococcus aureus 79% vs. 27%), complications (86% vs. 45%), recurrence (29% vs. 11%) and 30-day mortality (0% vs. 7%).

CONCLUSION

ND-RSIE is relatively rare and differs with regards to epidemiology, clinical characteristics and complications compared with left-sided IE and cardiac device RSIE, but has a favourable prognosis. Forty percent of ND-RSIE occurs among PWID, which is associated with frequent complications but a very low mortality.

Incidence, Risk Factors and Subsequent Prognostic Impact of New-Onset Atrial Fibrillation in Infective Endocarditis

BACKGROUND

Few studies with a large sample size have been performed to evaluate the incidence, risk factors and prognostic value of new-onset atrial fibrillation (AF) in patients with infective endocarditis (IE).Methods and Results:A total of 1,063 IE patients were included and 83 developed new AF. Compared with no-AF, the incidence of in-hospital death (6.0% vs. 22.9%, P<0.001) was higher in patients with new-onset AF. New-onset AF was independently associated with increased risk of in-hospital (adjusted odds ratio [OR]=3.92, P=0.001) and 1-year death (adjusted hazard ratio=2.91, P=0.001), while prior AF was not an independent factor. Kaplan-Meier curve analysis demonstrated new-onset AF mainly affected short-term death (180 days). Age (OR=1.04, P<0.001), rheumatic heart disease (OR=1.88, P=0.022), NYHA Class III or IV (OR=2.09, P=0.003), and left atrial diameter (LAD; OR=1.05, P=0.006) were independent risk factors for development of new AF.

CONCLUSIONS

New-onset AF, not prior AF, was a prognostic factor in IE patients, which was mainly associated with increased risk of short-term death. Patients with concomitant rheumatic heart disease, poor cardiac function, and larger LAD had higher risk of developing new AF.

Valve regurgitation in patients surviving endocarditis and the subsequent risk of heart failure

BACKGROUND

Significant valve regurgitation is common in patients surviving native valve infective endocarditis (IE), however the associated risk of heart failure (HF) subsequent to hospital discharge after IE is sparsely described.

METHODS

We linked data from the East Danish Endocarditis Registry with administrative registries from 2002 to 2016 and included patients treated medically for IE who were discharged alive. Left-sided valve regurgitation was assessed by echocardiography at IE discharge and examined for longitudinal risk of HF. Multivariable adjusted Cox analysis was used to assess the associated risk of HF in patients with regurgitation (moderate or severe) compared with patients without regurgitation.

RESULTS

We included 192 patients, 87 patients with regurgitation at discharge (30 with aortic regurgitation and 57 with mitral regurgitation) and 105 patients without. The cumulative risk of HF at 5 years of follow-up was 28.7% in patients with regurgitation at IE discharge and 12.4% in patients without regurgitation; the corresponding multivariable adjusted HR was 3.53 (95% CI 1.72 to 7.25). We identified an increased associated risk of HF for patients with aortic regurgitation (HR=2.91, 95% CI 1.14 to 7.43) and mitral regurgitation (HR=3.95, 95% CI 1.80 to 8.67) compared with patients without regurgitation. During follow-up, 21.9% and 5.7% underwent left-sided valve surgery among patients with and without regurgitation.

CONCLUSION

In patients surviving IE, treated medically, we observed that severe or moderate left-sided native valve regurgitation was associated with a significantly higher risk of HF compared with patients without regurgitation at IE discharge. Close monitoring of these patients is needed to initiate surgery timely.

Short- and long-term mortality in patients with left-sided infective endocarditis not undergoing surgery despite indication

INTRODUCTION AND OBJECTIVES

In infective endocarditis (IE), decisions on surgical interventions are challenging and a high percentage of patients with surgical indication do not undergo these procedures. This study aimed to evaluate the short- and long-term prognosis of patients with surgical indication, comparing those who underwent surgery with those who did not.

METHODS

We included 271 patients with left-sided IE treated at our institution from 2003 to 2018 and with an indication for surgery. There were 83 (31%) surgery-indicated not undergoing surgery patients with left-sided infective endocarditis (SINUS-LSIE). The primary outcome was all-cause death by day 60 and the secondary outcome was all-cause death from day 61 to 3 years of follow-up. Multivariable Cox regression and propensity score matching were used for the analysis.

RESULTS

At the 60-day follow-up, 40 (21.3%) surgically-treated patients and 53 (63.9%) SINUS-LSIE patients died (P <.001). Risk of 60-day mortality was higher in SINUS-LSIE patients (HR, 3.59; 95%CI, 2.16-5.96; P <.001). Other independent predictors of the primary endpoint were unknown etiology, heart failure, atrioventricular block, and shock. From day 61 to the 3-year follow-up, there were no significant differences in the risk of death between surgically-treated and SINUS-LSIE patients (HR, 1.89; 95%CI, 0.68-5.19; P=.220). Results were consistent after propensity score matching. Independent variables associated with the secondary endpoint were previous IE, diabetes mellitus, and Charlson index.

CONCLUSIONS

Two-thirds of SINUS-LSIE patients died within 60 days. Among survivors, the long-term mortality depends more on host conditions than on the treatment received during admission.

Aminoglycosides for infective endocarditis: time to say goodbye?

BACKGROUND

Based on experimental studies showing synergism with β-lactams and glycopeptides, aminoglycosides have long been considered essential in the treatment of infective endocarditis (IE). However, their use is associated with a high risk of renal failure, especially in elderly patients.

AIMS

The aim of this narrative review was to summarize the evidence to support reducing or even avoiding the use of aminoglycosides for the treatment of IE. We also analysed data supporting the use of aminoglycosides in specific subgroup of IE patients.

SOURCES

PubMed database was searched up to July 2019 to identify relevant studies.

CONTENTS

Recent European Guidelines reduced the use of aminoglycosides in IE, no longer recommended in Staphylococcus aureus native-valve IE, and shortened to 2 weeks for IE related to Enterococcus faecalis and streptococci with penicillin MIC >0.125 μg/mL. In addition, an alternative regimen without aminoglycosides (ampicillin or amoxicillin plus ceftriaxone) is proposed for E. faecalis. Observational studies suggested that gentamicin would not be necessary in the case of staphylococcal prosthetic valve IE as long as rifampicin is maintained. Recent clinical studies showed that for streptococcal IE, gentamicin could be restricted to isolates with penicillin MIC >0.5 μg/mL. For the empirical and definitive treatment of E. faecalis IE, amoxicillin or ampicillin plus ceftriaxone may be considered, irrespective of high-level of aminoglycoside resistance.

IMPLICATIONS

In a scenario of progressive increase in the age and frailty of IE patients, the use of aminoglycosides can be reduced or avoided in ~90% cases. This should result in reduced incidence of renal failure, an important prognostic factor in IE.

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.

Prognosis of Streptococcus pneumoniae endocarditis in France, a multicenter observational study (2000-2015)

BACKGROUND

Streptococcus pneumoniae is responsible for <2% of infective endocarditis (IE). The aim of this study was to assess the prognosis of pneumococcal IE.

METHODS

This multicentric observational retrospective study included adult patients presenting with definite S. pneumoniae IE according to modified Dukes criteria from four French university hospitals over a 15-year period, January 2000-December 2015. Survival rate at 90 days and 2 years after diagnosis, appropriateness of antibiotherapy, and pneumococcal vaccination status were determined. Risk factors for mortality were studied by univariate analysis.

RESULTS

Of 3886 patients admitted with IE during the study period, 50 (1.3%) had pneumococcal IE, mostly males (n = 38, 76%), with a mean age of 60 ± 14 years. Predisposing conditions for IE or for invasive pneumococcal disease (IPD) involved 24% and 78% of the cases, respectively. Only 2 patients were vaccinated against pneumococcus before IE and 13 (26%) after IE. Antimicrobial strategy was in accordance with the 2015 ESC Guidelines in 28%. Cardiac surgery was performed in 56%, and was associated with better survival (p = 0.012). In the 40 patients followed until 2 years, the survival rate was 67%, deaths occurring mostly before 90 days. Age ≥ 65 was a risk factor for mortality (p = 0.011).

CONCLUSION

Pneumococcal IE remains rare but with a poor prognosis. Resort to surgery is yet to be determined. Predisposing conditions for IPD are the main factors leading to pneumococcal IE. They could be prevented by vaccine coverage improvement.

Gastric Adenocarcinoma Associated with Acute Endocarditis of the Aortic Valve and Coronary Artery Disease in a 61-Year-Old Male with Multiple Comorbidities-Combined Surgical Management-Case Report

The case of a 61-year-old male with a recent total gastrectomy for a hemorrhagic gastric tumor is presented, with the important co-morbidities of type II diabetes mellitus requiring insulin, chronic hepatitis C with liver dysfunction, stage II essential hypertension, chronic stage III renal disease peripheral type II aorto-iliac disease with stage II ischemia of both legs, and chronic anemia. About one month following the gastrectomy, the patient presented with fever and acute inflammatory syndrome. Severe aortic insufficiency, aortic valvular vegetations, and positive blood cultures with Staphylococcus saprophytic were found. The diagnosis of infectious endocarditis on the aortic valve was established (positive blood cultures with echocardiographic features of vegetations, fever), and antibiotic treatment with Levofloxacin and Vancomycin was initiated. The evolution was favorable with the remission of the inflammatory syndrome and quick cessation of fever. However, the hemodynamic aspect showed progressive heart failure with acute pulmonary edema. The transesophageal echocardiographic examination confirmed the existence of severe aortic insufficiency and valvular vegetations with a left ventricular ejection fraction of 38%. The coronary angiography revealed double vessel disease. The calculated Euroscore II was 33.4%. Aortic valve replacement with porcine xenograft and double coronary artery bypass graft surgery was performed. The patient had a favorable postoperative course remaining afebrile and out of heart failure, with the markers of inflammation largely within normal limits. The left ventricular ejection fraction increased to 50%. The successful outcome of this case, represented by a rare association of cancer, endocarditis, and coronary disease, reveals the importance of the multidisciplinary teams involved in this case: gastroenterology, general surgery, cardiology, infectious diseases, cardiac surgery, and intensive care. Therefore, in such cases with high risk, complex patients, a strong collaboration between all specialties is needed to overcome all of the limitations of the patient's co-morbidities.

Native aortic versus mitral valve infective endocarditis: a nationwide registry study

Background

Native aortic and mitral valve infective endocarditis (AVE and MVE, respectively) are usually grouped together as left-sided native valve infective endocarditis (LNVE), while the differences between AVE and MVE have not yet been properly investigated. We aimed to compare AVE and MVE in regard to patient characteristics, microbiology and determinants of survival.

Methods

We conducted a retrospective study using the Swedish national registry on infective endocarditis, which contains nationwide patient data. The study period was 2007‒2017, and included cases were patients who had either AVE or MVE.

Results

We included 649 AVE and 744 MVE episodes. Staphylococcus aureus was more often the causative pathogen in MVE (41% vs 31%, p<0.001), whereas enterococci were more often the causative pathogen in AVE (14% vs 7.4%, p<0.001). Perivalvular involvement occurred more frequently in AVE (8.5% vs 3.5%, p<0.001) and brain emboli more frequently in MVE (21% vs 13%, p<0.001). Surgery for IE was performed more often (35% vs 27%, p<0.001) and sooner after diagnosis (6.5 days vs 9 days, p=0.012) in AVE than in MVE. Several risk predictors differed between the two groups.

Conclusions

The microbiology seems to differ between AVE and MVE. The causative pathogen was not associated with mortality in AVE. The between-group differences regarding clinical presentation and predictors of survival indicate that it may be important to differentiate AVE from MVE in the treatment of LNVE.

Effect of the type of surgical indication on mortality in patients with infective endocarditis who are rejected for surgical intervention

AIM

To evaluate the effect of the type of surgical indication on mortality in infective endocarditis (IE) patients who are rejected for surgery.

METHODS AND RESULTS

From January 2008 to December 2016, 2714 patients with definite left-sided IE were attended in the participating hospitals. One thousand six hundred and fifty-three patients (60.9%) presented surgical indications. Five hundred and thirty-eight patients (32.5%) presented surgical indications but received medical treatment alone. The indications for surgery in these patients were uncontrolled infection (366 patients, 68%), heart failure (168 patients, 31.3%) and prevention of embolism (148 patients, 27.6%). One hundred and thirty patients (24.2%) presented more than one indication. The mortality during hospital admission was 60% (323 patients). The in-hospital mortality of patients whose indication for surgery was heart failure, uncontrolled infection or risk of embolism was 75.6%, 61.4% and 54.7%, respectively (p < 0.001). Surgical indications due to heart failure (OR: 3.24; CI 95%: 1.99-5.9) or uncontrolled infection (OR: 1.83; CI 95%: 1.04-3.18) were independently associated with a fatal outcome during hospital admission. Mortality during the first year was 75.4%. The mortality during the first year in patients whose indication for surgery was heart failure, uncontrolled infection or risk of embolism was 85.9%, 76.7% and 72.7%, respectively (p = 0.016). Surgical indication due to heart failure (OR: 3.03; CI 95%: 1.53-5.98) were independently associated with fatal outcome during the first year.

CONCLUSIONS

The type of surgical indication is associated with mortality in IE patients who are rejected for surgical intervention.

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.

Teicoplanin for treating enterococcal infective endocarditis: A retrospective observational study from a referral centre in Spain

This study aimed to evaluate the effectiveness and safety of teicoplanin for treating enterococcal infective endocarditis (EIE). A retrospective analysis of a prospective cohort of definite EIE patients treated with teicoplanin in a Spanish referral centre (2000-2017) was performed. The primary outcome was mortality during treatment. Secondary outcomes were mortality during 3-month follow-up, adverse effects and relapse. A total of 22 patients received teicoplanin, 9 (40.9%) as first-line (8 Enterococcus faecium and 1 Enterococcus faecalis) and 13 (59.1%) as salvage therapy (13 E. faecalis). Median (IQR) age was 71.5 (58.3-78) years and Charlson comorbidity index was 4.5 (3-7). Five (22.7%) affected prosthetic valves. Median duration of treatment in survivors was 53 (42.5-61) days for antibiotics and 27 (17-41.5) days for teicoplanin [median dose 10 (10-10.8) mg/kg/day]. Reasons for teicoplanin use were resistance to β-lactams (40.9%), adverse events with previous regimens (31.8%) and outpatient parenteral antimicrobial therapy (OPAT) (27.3%). Teicoplanin was withdrawn due to adverse events in 2 patients (9.1%). Five patients (22.7%) died during treatment: four in the first-line (three with surgery indicated but not performed) and one in the salvage therapy group (surgery indicated but not performed). Two deaths (11.8%) occurred over the 3-month follow-up. There were no relapses during a median of 43.2 (22.1-69.1) months. Teicoplanin can be used as an alternative treatment for susceptible E. faecium IE and as a salvage therapy in selected patients with E. faecalis IE when adverse events develop with standard regimens or to allow OPAT.

Endocarditis in the Mediterranean Basin

Infective endocarditis is a severe disease with high mortality. Despite a global trend towards an increase in staphylococcal aetiologies, in older patients and a decrease in viridans streptococci, we have observed in recent studies great epidemiologic disparities between countries. In order to evaluate these differences among Mediterranean countries, we performed a PubMed search of infective endocarditis case series for each country. Data were available for 13 of the 18 Mediterranean countries. Despite great differences in diagnostic strategies, we could classify countries into three groups. In northern countries, patients are older (>50 years old), have a high rate of prosthetic valves or cardiac electronic implantable devices and the main causative agent is Staphylococcus aureus. In southern countries, patients are younger (<40 years old), rheumatic heart disease remains a major risk factor (45–93%), viridans streptococci are the main pathogens, zoonotic and arthropod-borne agents are frequent and blood culture–negative endocarditis remains highly prevalent. Eastern Mediterranean countries exhibit an intermediate situation: patients are 45 to 60 years old, the incidence of rheumatic heart disease ranges from 8% to 66%, viridans streptococci play a predominant role and zoonotic and arthropod-borne diseases, in particular brucellosis, are identified in up to 12% of cases.

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.

A pragmatic approach for mortality prediction after surgery in infective endocarditis: optimizing and refining EuroSCORE

OBJECTIVE

To simplify and optimize the ability of EuroSCORE I and II to predict early mortality after surgery for infective endocarditis (IE).

METHODS

Multicentre retrospective study (n = 775). Simplified scores, eliminating irrelevant variables, and new specific scores, adding specific IE variables, were created. The performance of the original, recalibrated and specific EuroSCOREs was assessed by Brier score, C-statistic and calibration plot in bootstrap samples. The Net Reclassification Index was quantified.

RESULTS

Recalibrated scores including age, previous cardiac surgery, critical preoperative state, New York Heart Association >I, and emergent surgery (EuroSCORE I and II); renal failure and pulmonary hypertension (EuroSCORE I); and urgent surgery (EuroSCORE II) performed better than the original EuroSCOREs (Brier original and recalibrated: EuroSCORE I: 0.1770 and 0.1667; EuroSCORE II: 0.2307 and 0.1680). Performance improved with the addition of fistula, staphylococci and mitral location (EuroSCORE I and II) (Brier specific: EuroSCORE I 0.1587, EuroSCORE II 0.1592). Discrimination improved in specific models (C-statistic original, recalibrated and specific: EuroSCORE I: 0.7340, 0.7471 and 0.7728; EuroSCORE II: 0.7442, 0.7423 and 0.7700). Calibration improved in both EuroSCORE I models (intercept 0.295, slope 0.829 (original); intercept -0.094, slope 0.888 (recalibrated); intercept -0.059, slope 0.925 (specific)) but only in specific EuroSCORE II model (intercept 2.554, slope 1.114 (original); intercept -0.260, slope 0.703 (recalibrated); intercept -0.053, slope 0.930 (specific)). Net Reclassification Index was 5.1% and 20.3% for the specific EuroSCORE I and II.

CONCLUSIONS

The use of simplified EuroSCORE I and EuroSCORE II models in IE with the addition of specific variables may lead to simpler and more accurate models.

Impact of Staphylococcus aureus phenotype and genotype on the clinical characteristics and outcome of infective endocarditis. A multicentre, longitudinal, prospective, observational study

OBJECTIVE

We aimed to evaluate the impact of Staphylococcus aureus phenotype (vancomycin MIC) and genotype (agr group, clonal complex CC) on the prognosis and clinical characteristics of infective endocarditis (IE).

METHODS

We performed a multicentre, longitudinal, prospective, observational study (June 2013 to March 2016) in 15 Spanish hospitals. Two hundred and thirteen consecutive adults (≥18 years) with a definite diagnosis of S. aureus IE were included. Primary outcome was death during hospital stay. Main secondary end points were persistent bacteraemia, sepsis/septic shock, peripheral embolism and osteoarticular involvement.

RESULTS

Overall in-hospital mortality was 37% (n = 72). Independent risk factors for death were age-adjusted Charlson co-morbidity index (OR 1.20; 95% CI 1.08-1.34), congestive heart failure (OR 3.60; 95% CI 1.72-7.50), symptomatic central nervous system complication (OR 3.17; 95% CI 1.41-7.11) and severe sepsis/septic shock (OR 4.41; 95% CI 2.18-8.96). In the subgroup of methicillin-susceptible S. aureus IE (n = 173), independent risk factors for death were the age-adjusted Charlson co-morbidity index (OR 1.17; 95% CI 1.03-1.31), congestive heart failure (OR 3.39; 95% CI 1.51-7.64), new conduction abnormality (OR 4.42; 95% CI 1.27-15.34), severe sepsis/septic shock (OR 5.76; 95% CI 2.57-12.89) and agr group III (OR 0.27; 0.10-0.75). Vancomycin MIC ≥1.5 mg/L was not independently associated with death during hospital nor was it related to secondary end points. No other genotype variables were independently associated with in-hospital death.

CONCLUSIONS

This is the first prospective study to assess the impact of S. aureus phenotype and genotype. Phenotype and genotype provided no additional predictive value beyond conventional clinical characteristics. No evidence was found to justify therapeutic decisions based on vancomycin MIC for either methicillin-resistant or methicillin-susceptible S. aureus.

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.

18F-FDG-PET/CT angiography in the diagnosis of infective endocarditis and cardiac device infection in adult patients with congenital heart disease and prosthetic material

OBJECTIVES

Infective endocarditis (IE) and cardiac device infection (CDI) are a major complication in the growing number of patients with congenital heart disease (CHD) reaching adulthood. We aimed to evaluate the added value of ¹⁸F-FDG-PET/CT angiography (PET/CTA) in the diagnosis of IE-CDI in adults with CHD and intravascular or intracardiac prosthetic material, in whom echocardiography (ECHO) and modified Duke Criteria (DC) have limitations because of the patients' complex anatomy.

METHODS

A prospective study was conducted in a referral center with multidisciplinary IE and CHD Units. PET/CTA and ECHO findings were compared in consecutive adult (≥18years) patients with CHD who have prosthetic material and suspected IE-CDI. The initial diagnosis using the DC and the diagnosis with the additional PET/CTA data (DC+PET/CTA) were compared with the final diagnostic consensus established by an expert team at three months.

RESULTS

Between November-2012 and April-2017, 25 patients (15 men; median age 40years) were included. Cases were initially classified as definite in 8 (32%), possible in 14 (56%) and rejected in 3 (12%). DC+PET/CTA allowed reclassification of 12/14 (86%) cases initially identified as possible IE. The sensitivity, specificity, PPV, NPV, and accuracy of DC at IE suspicion were 39.1%/83.3%/90.4%/25.5%/61.2%, respectively. The diagnostic performance increased significantly with addition of PET/CTA data: 87%/83.3%/95.4%/61.5%/85.1%, respectively. PET/CTA also provided an alternative diagnosis in 3 patients with rejected IE, and detected pulmonary embolisms in 3 patients.

CONCLUSIONS

PET/CTA was a useful diagnostic tool in the complex group of adult patients with CHD who have cardiac or intravascular prosthetic material and suspected IE or CDI, providing added diagnostic value to the modified DC (increased sensitivity) and improving case classification.

The impact of admission neutrophil-to-platelet ratio on in-hospital and long-term mortality in patients with infective endocarditis

BACKGROUND

Infective endocarditis (IE) is associated with increased neutrophil and reduced platelet counts. We assessed the relationship between the neutrophil-to-platelet ratio (NPR) on admission and adverse outcomes in patients with IE.

METHODS

Patients diagnosed with IE between January 2009 and July 2015 (n=1293) were enrolled, and 1046 were finally entered into the study. Study subjects were categorized into four groups according to NPR quartiles: Q1<18.9 (n=260); Q2: 18.9-27.7 (n=258); Q3: 27.7-43.3 (n=266); and Q4>43.3 (n=262). Cox proportional hazards regression was performed to identify risk factors for long-term mortality; the optimal cut-off was evaluated by receiver operating characteristic curves.

RESULTS

Risk of in-hospital death increased progressively with NPR group number (1.9 vs. 5.0 vs. 9.8 vs. 14.1%, p<0.001). The follow-up period was a median of 28.8 months, during which 144 subjects (14.3%) died. Long-term mortality increased from the lowest to the highest NPR quartiles (7.6, 11.8, 17.4, and 26.2%, respectively, p<0.001). Multivariate Cox proportional hazard analysis revealed that lgNPR (HR=2.22) was an independent predictor of long-term mortality. Kaplan-Meier survival curves showed that subjects in Q4 had an increased long-term mortality compared with the other groups.

CONCLUSIONS

Increased NPR was associated with in-hospital and long-term mortality in patients with IE. As a simple and inexpensive index, NPR may be a useful and rapid screening tool to identify IE patients at high risk of mortality.

Position paper for the evaluation and management of oral status in patients with valvular disease: Groupe de Travail Valvulopathies de la Société Française de Cardiologie, Société Française de Chirurgie Orale, Société Française de Parodontologie et d'Implantologie Orale, Société Française d'Endodontie et Société de Pathologie Infectieuse de Langue Française

Oral health is of particular importance in patients with heart valve diseases because of the risk of infective endocarditis. Recommendations for antibiotic prophylaxis before dental procedures have been restricted, but the modalities of oral evaluation and dental care are not detailed in guidelines. Therefore, a multidisciplinary working group reviewed the literature to propose detailed approaches for the evaluation and management of buccodental status in patients with valvular disease. Simple questions asked by a non-dental specialist may draw attention to buccodental diseases. Besides clinical examination, recent imaging techniques are highly sensitive for the detection of inflammatory bone destruction directly related to oral or dental infection foci. The management of buccodental disease before cardiac valvular surgery should be adapted to the timing of the intervention. Simple therapeutic principles can be applied even before urgent intervention. Restorative dentistry and endodontic and periodontal therapy can be performed before elective valvular intervention and during the follow-up of patients at high risk of endocarditis. The detection and treatment of buccodental foci of infection should follow specific rules in patients who present with acute endocarditis. Implant placement is no longer contraindicated in patients at intermediate risk of endocarditis, and can also be performed in selected high-risk patients. The decision for implant placement should follow an analysis of general and local factors increasing the risk of implant failure. The surgical and prosthetic procedures should be performed in optimal safety conditions. It is therefore now possible to safely decrease the number of contraindicated dental procedures in patients at risk of endocarditis.

The Changing Epidemiology of Infective Endocarditis in the Twenty-First Century

PURPOSE OF THE REVIEW

Infective endocarditis (IE) is a relatively infrequent infectious disease. It does, however, causes serious morbidity, and its mortality rate has remained unchanged at approximately 25%. Changes in IE risk factors have deeply impacted its epidemiology during recent decades but literature from low-income countries is very scarce. Moreover, prophylaxis guidelines have recently changed and the impact on IE incidence is still unknown.

RECENT FINDINGS

In high-income countries, the proportion of IE related to prior rheumatic disease has decreased significantly and has been replaced proportionally by cases related to degenerative valvulopathies, prosthetic valves, and cardiovascular implantable electronic devices. Nosocomial and non-nosocomial-acquired cases have risen, as has the proportion caused by staphylococci, and the median age of patients. In low-income countries, in contrast, rheumatic disease remains the main risk factor, and streptococci the most frequent causative agents. Studies performed to evaluate impact of guidelines changes' have shown contradictory results. The increased complexity of cases in high-income countries has led to the creation of IE teams, involving several specialties. New imaging and microbiological techniques may increase sensitivity for diagnosis and detection of IE cases. In low-income countries, IE remained related to classic risk factors. The consequences of prophylaxis guidelines changes are still undetermined.

Combined efficacy of C-reactive protein and red blood cell distribution width in prognosis of patients with culture-negative infective endocarditis

Objective

To evaluate the combined effect of C-reactive protein (CRP) and red blood cell distribution width (RDW) on the prediction of in-hospital and long-term poor outcomes in patients with blood culture-negative infective endocarditis (BCNE).

Results

Patients with high CRP and high RDW has the highest incidence of in-hospital death (2.3% vs. 7.8% vs. 5.6% vs. 17.5%, P < 0.001). CRP > 17.8 mg/L (odds ratio [OR]=2.41, 95% confidence interval [CI], 1.06–5.51, P = 0.037), RDW >16.3 (OR = 2.29, 95% CI, 1.10–4.77, P = 0.027), and these two values in combination (OR = 3.15, 95% CI, 1.46–6.78, P=0.003) were independently associated with in-hospital death. Patients with RDW > 16.3 had higher long-term mortality (P = 0.003), while no significant correlation was observed for CRP (P = 0.151).

Materials and Methods

In total, 572 participants with BCNE were consecutively enrolled. They were classified into four groups based on the optimal CRP and RDW cut-off values (which were determined using a receiver operating characteristic analysis): low CRP and low RDW (n = 216), high CRP and low RDW (n = 129), low CRP and high RDW (n = 107), and high CRP and high RDW (n = 120).

Conclusions

Increased CRP and RDW, especially in combination, are independently associated with in-hospital death in BCNE. RDW, but not CRP, has long-term prognostic value.