Infective endocarditis: a comparison of international guidelines

Temporal changes in infective endocarditis guidelines during the last 12 years: High-level evidence needed

BACKGROUND

Infective endocarditis (IE) is a complex disease necessitating extensive clinical guidelines. The guidelines from the American Heart Association (AHA) and the European Society of Cardiology (ESC) have been markedly extended during the last 12 years. We examined the evidence base for these changes.

METHODS

IE guidelines published by AHA and ESC were reviewed. We categorized and combined guidelines into 3 time periods: (1) 2004 (AHA) and 2005 (ESC), (2) 2007 (AHA) and 2009 (ESC), and (3) 2015 (AHA) and 2015 (ESC). Number of recommendations, classes of recommendations (I, II, or III), and levels of evidence (LOE) (A, B, or C) were assessed and the changes over time.

RESULTS

From period 1 to period 3, we found a statistically significant increase in total number of IE recommendations from 37 to 253 (P<.01), a 6.8-fold increase. There were a significant decrease in LOE A (from 7 [20.0%] in period 1 to 4 [1.6%] in period 3, P<.0001, a 57% decrease), a nonsignificant decrease in LOE B recommendations (from 17 [48.6%] in period 1 to 115 [45.9%] in period 3, P=.29, a 6.8-fold increase), and a significant increase in LOE C recommendations (from 11 [31.4%] in period 1 to 134 [53.0%] in period 3, P=.02, a 12.2-fold increase).

CONCLUSIONS

The number of IE guideline recommendations has increased 6- to 7-fold during the last decade without a corresponding increase in evidence. These results highlight the strong need for more clinical studies to improve the level of evidence in IE guidelines.

Prevalence and intensity of bacteraemia following orthodontic procedures

BACKGROUND

There is a possibility that bacteria may enter the blood stream during some non-surgical manipulation procedures, which include orthodontic treatment procedures (alginate impression taking, separator placement, band cementation, and archwire change).

OBJECTIVES

The aim of this study was to determine the prevalence and intensity of bacteraemia associated with orthodontic procedures in patients seen at the Lagos University Teaching Hospital, Nigeria.

METHODOLOGY

A total of 100 subjects who presented at the Orthodontic Clinic of the Lagos University Teaching Hospital and who met the inclusion criteria were recruited for the study. Four orthodontic procedures were investigated: alginate impression taking, separator placement, band cementation and archwire placement. Subjects were randomly placed in one of the four procedure groups. Peripheral blood was collected for microbiologic analysis before the orthodontic procedures and within 2 min of completion of the procedures. The BACTEC automated blood culture system and the lysis filtration method of blood culturing were used for microbiological analysis of the blood samples. The Wilcoxon signed rank test, the McNemar χ(2) test, the Mann-Whitney U-test, and Spearman and point bi-serial correlations were used for statistical evaluation at the P<0.05 level.

RESULTS

A significant increase in the prevalence and intensity of bacteraemia was observed following separator placement. The predominant bacteria isolated from the blood cultures were Streptococcus viridans and Staphylococcus species.

CONCLUSION

Separator placement induced the highest levels of bacteraemia. Use of a 0.2% chlorhexidine mouth rinse is recommended prior to separator placement in orthodontic patients.

The influence of direct rigid laryngoscopy on the nosocomial colonization and bacteremia

OBJECTIVE

Direct rigid laryngoscopy (DRL) is a relatively simple and well-tolerated procedure that can provide both diagnostic and therapeutic benefits. There are no data regarding the risk of acquiring bacteremia after DRL. The purpose of this prospective study was to assess the frequency of bacteremia and nosocomial colonization following DRL and to identify possible risk factors for the development of these complications.

METHODS

In this study, 55 consecutive patients with benign or malignant laryngeal pathologies undergoing DRL were included between January 2010 and January 2011. The patients have benign laryngeal lesions and suspicious malignancy. In appropriate circumstances of each patient before intubation and at postoperative 24 hours of throat swab, samples were taken in the transport medium of the patients who underwent planned DRL and underwent surgery. The samples were evaluated in our Microbiology Department. Blood cultures were performed using automated system at postoperative 5 and 24 hours. For each patient at preoperative and postoperative period, C-reactive protein levels in blood samples were measured. SPPS 16 package program was used for statistical analysis.

RESULTS

The distribution of sex was 45 males and 10 females with average age of 51.4 (between 23 and 99 years). Patients who had malignant lesions (n = 17) accounted for 30.9% of all patients. Preoperative Candida colonization was recovered from the cultures obtained from 9 oropharyngeal specimens (16.4%). Postoperative oropharyngeal nosocomial bacteria colonization was observed in 14 patients (25.5%). Nosocomial colonization was found related to malignancy (P = 0.014). C-reactive protein levels of patients before and after surgery were not statistically significant (P > 0.05). At postoperative 5 and 24 hours, blood cultures of all patients were negative. Postsurgical bacteremia was not observed.

CONCLUSIONS

Although there is no association between DRL and bacteremia, nosocomial colonization may be significant. Nosocomial colonization possesses a risk of development of infection especially in patients with malignancy.

Characteristics of Children Hospitalized With Infective Endocarditis

Background— Infective endocarditis in children is rare, and most reports describe the experience in referral centers. The purpose of our study was to assess the characteristics of children with infective endocarditis in a large national sample.

Methods and Results— We analyzed hospital discharge records with International Classification of Diseases , ninth revision, codes indicating infective endocarditis among admissions of patients <21 years of age in the Kids’ Inpatient Databases 2000 and 2003; analyses for the 2 years were combined. In 1588 hospitalizations, the age distribution was bimodal, with peaks in infancy and late adolescence. The organism was coded in 632 admissions; Staphylococcus aureus was most common (57%), followed by the viridans group of streptococci (20%). Preexisting heart disease was present in 662 patients admitted (42%), among whom 81% had congenital heart disease, 8% had prosthetic valve endocarditis, and 5% had rheumatic heart disease. In-hospital mortality occurred in 84 patients (5%), 38 with preexisting heart disease. Death occurred in 12 of 25 patients (48%) with tetralogy of Fallot and pulmonary atresia, and 4 of 54 (8%) with prosthetic valve endocarditis. Among 46 deaths without preexisting heart disease, S aureus was the causative organism in 13 of 14 patients (93%) beyond infancy; among 32 infants who died, 10 (31%) were premature.

Conclusions— In 2000 and 2003, we found a continuing shift in the epidemiology of pediatric infective endocarditis toward a higher proportion of children without preexisting heart disease. Risk factors for mortality included some forms of congenital heart disease and, among patients without preexisting heart disease, premature/neonatal age and S aureus as an etiologic agent.

Infective endocarditis after body art: a review of the literature and concerns

PURPOSE

Infective endocarditis (IE) is a rare but dangerous complication of tattooing and body piercing in adolescents and young adults 15-30 years of age, with and without congenital heart disease (CHD). Because body art, including tattooing and piercing, is increasing and IE cases continue to be reported in the literature, a longitudinal assessment of IE and body art cases is important to examine for trends.

METHODS

A 22-year (1985-2007) longitudinal electronic Medline and Scopus review of all published cases of IE and body art was conducted.

RESULTS

In all, 22 specific cases of IE spanning 1991-2007 have been reported that were associated with piercing the tongue (seven), ear lobes (six), navel (five), lip (one), nose (one), and nipple (one), and reported in one heavily tattooed person; other general IE cases have also been mentioned. Twelve cases were in females, and one patient died; nine of these individuals had CHD. Twenty-one cases have been published in the 10 years from 1997-2007.

CONCLUSIONS

Although there is no denominator to assess the real risk, this review provides more evidence of IE and body art concerns, and should stimulate further discussion regarding IE antibiotic prophylaxis. It is believed that IE is triggered by normal flora at the body art site, microorganism colonization around the jewelry, or by a localized site infection that stimulates episodes of transient bacteremia (commonly caused by staphylococi) and then seeds various areas of the heart. Frequently in such cases the mitral or aortic valves need to be replaced. For individuals with CHD who want body art, prophylactic antibiotic regimens have been suggested since 1999. Millions of tattoos and body piercings are done yearly, and more IE cases are therefore suspected. An international electronic repository of body art complications would provide better documentation. Body art procurement for many persons in this age group is a matter of "when, not if"; thus proactive, frequent, targeted educational strategies for adolescents and artists practicing body art are suggested.