Risk factors for infective endocarditis: oral hygiene and nondental exposures

Simultaneous Periprosthetic Joint Infection and Infective Endocarditis: Prevalence, Risk Factors, and Clinical Presentation

BACKGROUND

Infective endocarditis (IE) and periprosthetic joint infections (PJI) occur due to hematogenous bacterial spread, theoretically increasing the risk for concurrent infections. There is a scarcity of literature investigating this specific association. We aimed to assess the prevalence, comorbidities, and clinical presentation of patients who have simultaneous PJI and IE.

METHODS

We retrospectively identified 655 patients (321 men, 334 women; 382 total hip arthroplasty, 273 total knee arthroplasty) who developed a PJI from July 1, 2015, to December 31, 2020, at one institution. There were two groups created: patients diagnosed with PJI with IE (PJI + IE) and PJI patients who did not have IE (PJI). We analyzed clinical outcomes and comorbidities.

RESULTS

There were nine patients who had PJI with IE (1.4% of PJI patients). The C-reactive protein (170.9 versus 78, P = 0.026), Elixhauser comorbidity score (P = 0.002), length of hospital stay (10.9 versus 5.7 days, P = 0.043), and the 2-year postdischarge mortality rate (55.6 versus 9.0%, P = 0.0007) were significantly greater in the PJI + IE group. Comorbidities such as iron deficiency anemia (P = 0.03), coagulopathy (P = 0.02), complicated diabetes mellitus (P = 0.02), electrolyte disorders (P = 0.01), neurologic disease (P = 0.004), paralysis (P = 0.04), renal failure (P = 0.0001), and valvular disease (P = 0.0008) occurred more frequently in the PJI + IE group. Modified Duke's criteria were met for possible or definite IE in eight of the nine patients.

CONCLUSIONS

Concurrent PJIs and IE, although rare, are a potentially devastating disease state with increased length of hospital stay and 2-year mortality rates. This emphasizes the need for appropriate IE workups in patients who have a PJI. The modified Duke's criteria are effective in establishing a diagnosis for IE in this scenario.

Cardiac evaluation in patients awaiting kidney transplant-position statement of the Cardiological Society of India and Indian Society of Nephrology

Cardiovascular diseases are a major cause of death after kidney transplantation. This statement addresses preoperative cardiac decision-making and management with the aim of assessing and reducing the risk of the kidney transplant surgery. Important issues from a clinician's perspective include the basic cardiovascular workup of these patients, coronary evaluation and management of coronary artery disease, valvular heart disease and left ventricular systolic dysfunction. Recovery left ventricular function after kidney transplant is discussed. In addition, the use of cardiovascular drugs in patients with special emphasis on antiplatelets and anticoagulants in patients planned for kidney transplant is also discussed.

Peripheral vascular emboli in patients with infective endocarditis are common

OBJECTIVE

Infective endocarditis (IE) is associated with significant morbidity and mortality and places patients at risk for subsequent peripheral vascular emboli. Our goals were to analyze the incidence of peripheral emboli and their associated complications and outcomes.

METHODS

A retrospective single-center review of all patients with IE from 2013 through 2021 was performed. Patients with IE who had peripheral vascular emboli were identified, and their clinical characteristics and outcomes were analyzed.

RESULTS

Overall, 525 patients with IE were identified, and of these, 14.3% had peripheral emboli. In patients with peripheral emboli, the average age was 47 years, and 58.7% were of male gender; race composition included 56% White and 24% Black patients. Comorbidities included hypertension (49.3%), congestive heart failure (30.7%), prior valve replacement/repair (26.7%), and diabetes (24%). Intravenous drug use (62.7%) was the most common cause of IE, followed by non-dental infectious sources (16%), an indwelling catheter (6.7%), or dental infection (4%). Valve distribution was mitral (45.3%), aortic (28%), and tricuspid (24%). Gram-positive organisms, including methicillin-resistant Staphylococcus aureus (30.7%) and methicillin-susceptible Staphylococcus aureus (25.3%), were the most commonly identified bacteria, and Candida was identified in 6.7% of patients. Splenic (57.3%; n = 43) and renal (32%; n = 24) arteries were the most common locations for peripheral vascular emboli, followed by lower (28%; n = 21) and upper extremity (2.7%; n = 2) arteries. Cerebrovascular emboli occurred concurrently in 20 patients (26.7%) with other peripheral emboli. The most common locations for embolism that underwent an intervention were the common femoral (54.4%), superficial femoral (54.4%), popliteal (36.4%), tibial (27.3%), deep femoral (27.3%), peroneal (9.1%), superior mesenteric (SMA) (9.1%), and brachial (9.1%) arteries. Although open surgical embolectomy (81.8%) was the most common intervention, one patient underwent an endovascular intervention. Other interventions included two lower extremity amputations (one primary and one after embolectomy), one infrapopliteal bypass for a popliteal artery occlusion, and an attempted SMA embolectomy stopped due to cardiac arrest. One patient with splenic and cerebrovascular emboli had a mycotic thoracic aneurysm, which was deemed nonoperative. At 30 days, 1 year, and 5 years, 92%, 83%, and 65% of patients with IE survived, respectively; among those with IE and peripheral emboli, 86%, 71%, and 43% of patients survived, respectively (P = .01). Those who underwent peripheral vascular interventions had a 1- and 5-year survival of 45.5% and 36.6%, respectively.

CONCLUSIONS

Peripheral vascular emboli are common in patients with IE and frequently occur in association with cerebral embolic events. Overall morbidity and mortality are high in this young population, in particular for those undergoing interventions.

Complicated infective endocarditis of the bioprosthetic mitral valve following the transcatheter mitral valve-in-valve procedure: a case report and literature review

Background

Since the transcatheter valve-in-valve (ViV) procedure was introduced in 2007, a few cases of infective endocarditis (IE) following the ViV procedure have been reported, which can be predisposed by older age, pre-existing medical conditions, and procedural techniques. Paravalvular abscesses constitute a rare complication of IE, resulting from extending IE beyond the valve annulus, less commonly caused by Klebsiella species. This complication is more common in prosthetic valves, particularly bioprosthetic valves.

Case summary

We describe a 75-year-old woman with Churg-Strauss syndrome and diabetes mellitus who underwent surgical replacement of bioprosthetic aortic and mitral valves 11 years ago. One year ago, she had a transcatheter mitral ViV procedure due to bioprosthetic mitral valve degeneration. The patient was referred to our centre with fatigue and fever, alongside elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein. Blood and urine cultures tested positive for Klebsiella oxytoca. Echocardiographic assessments revealed a paravalvular abscess (13 × 8 mm) in the posterolateral side of the bioprosthetic mitral valve, fistulized into the left ventricle. The patient received treatment with vancomycin, meropenem, and colistin and was a candidate for surgery. Eleven days after the patient's admission, she passed away.

Discussion

This study underscores the novelty of IE complicated with paravalvular abscess following the ViV procedure. In such cases, a multidisciplinary approach and timely surgical interventions are crucial for optimal patient outcomes.

Heart failure - An unexplored risk factor for infective endocarditis after pacemaker implantation

BACKGROUND

With the widespread use of permanent pacemakers (PPM), and increased mortality associated with pacemaker endocarditis, it is essential to evaluate comorbidities that could potentially increase the risk of infective endocarditis (IE). Heart failure (HF), a common comorbidity, has not been well studied as an independent risk factor for development of IE in individuals with PPM.

METHODS

The US National Inpatient Sample database was used to sample individuals with PPM. Patients with concomitant implantable cardioverter defibrillator, acute heart failure, history of endocarditis, intravenous drug use, prosthetic heart valves, or central venous catheter infection were excluded. Propensity matching was performed to match patients with and without HF. Pre- and post-match logistic regression was performed to assess HF as an independent risk factor for IE. A subgroup analysis was performed comparing IE rates between patients with HF with reduced (HFrEF) vs preserved (HFpEF) ejection fraction.

RESULTS

Out of 333,571 patients with PPM included in the study, 121,862 (37 %) had HF. HF patients were older and had a higher prevalence of females. All comorbidities except for dental disease and cancer were more prevalent in the HF group. Patients with HF were 1.30 times more likely to develop IE [OR: 1.30 (1.16-1.47); p < 0.001]. The two cohorts were then matched for age, gender, and 20 comorbidities using a 1:1 propensity score matching algorithm. After matching, HF was still independently associated with increased risk of IE [OR: 1.62 (1.36-1.93); p < 0.001]. In our sub-group analysis, HFrEF and HFpEF patients had similar IE rates.

CONCLUSION

In PPM population, HF was associated with an increased risk of IE compared to those without HF. We hypothesize that HF being a low-flow and high-inflammatory state might have contributed to this increased risk. Larger studies are required to corroborate our findings and evaluate the need for antimicrobial prophylaxis for this population.

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.

Exploring the link between poor oral hygiene and mesh infection after hernia repair: a systematic review and proposed best practices

BACKGROUND

There is a reasonable body of evidence around oral/dental health and implant infection in orthopaedic and cardiovascular surgery. Another large area of surgical practice associated with a permanent implant is mesh hernia repair. This study aimed to review the evidence around oral/dental health and mesh infection.

METHODS

The research protocol was registered in PROSPERO (CRD42022334530). A systematic review of the literature was undertaken according to the PRISMA 2020 statement. The initial search identified 582 publications. A further four papers were identified from references. After a review by title and abstract, 40 papers were read in full text. Fourteen publications were included in the final review, and a total of 47,486 patients were included.

RESULTS

There is no published evidence investigating the state of oral hygiene/health and the risk of mesh infection or other infections in hernia surgery. Improvement in oral hygiene/health can reduce surgical site infection and implant infection in colorectal, gastric, liver, orthopaedic and cardiovascular surgery. Poor oral hygiene/health is associated with a large increase in oral bacteria and bacteraemia in everyday activities such as when chewing or brushing teeth. Antibiotic prophylaxis does not appear to be necessary before invasive dental care in patients with an implant.

CONCLUSION

Good oral hygiene and oral health is a strong public health message. The effect of poor oral hygiene on mesh infection and other complications of mesh hernia repair is unknown. While research is clearly needed in this area, extrapolating from evidence in other areas of surgery where implants are used, good oral hygiene/health should be encouraged amongst hernia patients both prior to and after their surgery.

Nondental Invasive Procedures and Risk of Infective Endocarditis: Time for a Revisit: A Science Advisory From the American Heart Association

There have been no published prospective randomized clinical trials that have: (1) established an association between invasive dental and nondental invasive procedures and risk of infective endocarditis; or (2) defined the efficacy and safety of antibiotic prophylaxis administered in the setting of invasive procedures in the prevention of infective endocarditis in high-risk patients. Moreover, previous observational studies that examined the association of nondental invasive procedures with the risk of infective endocarditis have been limited by inadequate sample size. They have typically focused on a few potential at-risk surgical and nonsurgical invasive procedures. However, recent investigations from Sweden and England that used nationwide databases and demonstrated an association between nondental invasive procedures, and the subsequent development of infective endocarditis (in particular, in high-risk patients with infective endocarditis) prompted the development of the current science advisory.

From Cardiac Mystery to Dental Discovery: Resolving Recurrent Infection in a Prosthetic Heart Valve Patient

We present the case of a 71-year-old female with a history of surgical bioprosthetic aortic valve replacement who developed a liquefactive abscess near the mitral valve trigone following Streptococcus gallolyticus bacteremia. The patient initially presented with dyspnea and symptoms of an upper respiratory tract infection. A trans-esophageal echocardiogram revealed mitral valve vegetation and a possible source of sepsis near the prosthetic aortic valve. However, it was the identification of multiple silent dental abscesses during a routine dental check-up that led to the resolution of the patient's symptoms and the eradication of the infectious process. This case highlights the importance of considering dental infections as a potential cause of recurrent bacteremia and infectious complications in patients with prosthetic heart valves.

Long-term incidence of infective endocarditis among patients with congenital heart disease

BACKGROUND

Patients with congenital heart disease (CHD) are at lifelong high risk of infective endocarditis (IE). The risk of IE presumably differs among different CHD, but little knowledge exists on the area.

METHODS

In this observational cohort study, all CHD-patients born in 1977 to 2018 were identified using Danish nationwide registries and followed from the date of birth until first-time IE, emigration, death, or end of study (December 31, 2018). The comparative risk of IE among CHD-patients vs age- and sex-matched controls from the background population was assessed. The risk of IE was stratified according to the type of CHD and factors associated with IE including sex and relevant time-varying coefficients (ie, cyanosis, cardiac prostheses, diabetes mellitus, chronic kidney disease, and cardiac implantable electronic devices) were examined using Cox-regression analysis.

RESULTS

A total of 23,464 CHD-patients (50.0% men) were identified and matched with 93,856 controls. During a median follow-up of 17.7 years, 217(0.9%) CHD-patients and 4(0.0%) controls developed IE, corresponding to incidence rates of 5.2(95%CI 4.6-6.0) and 0.02(95%CI 0.01-0.1) per 10,000 person-years, respectively. The incidence of IE was greatest among patients with tetralogy of fallot, malformations of the heart chambers (including transposition of the great arteries, univentricular heart, and truncus arteriosus), atrioventricular septal defects, and heart valve defects. Factors associated with IE among CHD-patients included male sex, cyanosis, cardiac prostheses, chronic kidney disease, and cardiac implantable electronic devices.

CONCLUSIONS

CHD-patients have a substantially higher associated incidence of IE than the background population. With the increasing longevity of these patients, relevant guidelines concerning preventive measures are important.

Mitral Valve Endocarditis in Patient Awaiting TAVI: A Case Report

Background

The current literature focuses on the risk of infective endocarditis (IE) following transcatheter aortic valve implantation (TAVI). However, the risk of IE in patients waiting for TAVI is not well-studied. We present a unique case of a patient waiting for TAVI with decompensated heart failure who was found to have a large mitral vegetation, and consider risk factors for the development of IE in this population.

Case description

We report the case of an 85-year-old male with severe aortic stenosis and recurrent small bowel angiodysplasias, requiring frequent blood transfusions and intravenous iron. He presented to a peripheral hospital in decompensated heart failure. Transfer was arranged to our center to expedite TAVI, under the premise that worsening aortic stenosis precipitated his decompensated state. Prior to TAVI, an echocardiogram was done, and demonstrated a 30 × 18 mm mass on the mitral valve with anterior leaflet perforation and severe mitral regurgitation. The findings were consistent with IE, and the TAVI was cancelled. Despite antibiotic therapy, the patient unfortunately deteriorated and palliative care was provided.

Conclusions

This case highlights the need for further research regarding the risk of IE in patients waiting for TAVI. Current literature focuses on the development and management of IE following TAVI. Clinicians must understand that TAVI candidates have multiple risk factors for IE, including valvular disease, age, and comorbidities. IE should be considered as a possible cause for decompensated heart failure in patients awaiting TAVI.

Expanding utility of cardiac computed tomography in infective endocarditis: A contemporary review

There is increasing evidence on the utility of cardiac computed tomography (CCT) in infective endocarditis (IE) to investigate the valvular pathology, the extra-cardiac manifestations of IE and pre-operative planning. CCT can assist in the diagnosis of perivalvular complications, such as pseudoaneurysms and abscesses, and can help identify embolic events to the lungs or systemic vasculature. CCT has also been shown to be beneficial in the pre-operative planning of patients by delineating the coronary artery anatomy and the major cardiovascular structures in relation to the sternum. Finally, hybrid nuclear/computed tomography techniques have been shown to increase the diagnostic accuracy in prosthetic valve endocarditis. This manuscript aims to provide a contemporary update of the existing evidence base for the use of CCT in IE.

Antibiotic prophylaxis for preventing bacterial endocarditis following dental procedures

BACKGROUND

Infective endocarditis is a severe infection arising in the lining of the chambers of the heart. It can be caused by fungi, but most often is caused by bacteria. Many dental procedures cause bacteraemia, which could lead to bacterial endocarditis in a small proportion of people. The incidence of bacterial endocarditis is low, but it has a high mortality rate.  Guidelines in many countries have recommended that antibiotics be administered to people at high risk of endocarditis prior to invasive dental procedures. However, guidance by the National Institute for Health and Care Excellence (NICE) in England and Wales states that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. This is an update of a review that we first conducted in 2004 and last updated in 2013.

OBJECTIVES

Primary objective To determine whether prophylactic antibiotic administration, compared to no antibiotic administration or placebo, before invasive dental procedures in people at risk or at high risk of bacterial endocarditis, influences mortality, serious illness or the incidence of endocarditis. Secondary objectives To determine whether the effect of dental antibiotic prophylaxis differs in people with different cardiac conditions predisposing them to increased risk of endocarditis, and in people undergoing different high risk dental procedures. Harms Had we foundno evidence from randomised controlled trials or cohort studies on whether prophylactic antibiotics affected mortality or serious illness, and we had found evidence from these or case-control studies suggesting that prophylaxis with antibiotics reduced the incidence of endocarditis, then we would also have assessed whether the harms of prophylaxis with single antibiotic doses, such as with penicillin (amoxicillin 2 g or 3 g) before invasive dental procedures, compared with no antibiotic or placebo, equalled the benefits in prevention of endocarditis in people at high risk of this disease.

SEARCH METHODS

An information specialist searched four bibliographic databases up to 10 May 2021 and used additional search methods to identify published, unpublished and ongoing studies SELECTION CRITERIA: Due to the low incidence of bacterial endocarditis, we anticipated that few if any trials would be located. For this reason, we included cohort and case-control studies with suitably matched control or comparison groups. The intervention was antibiotic prophylaxis, compared to no antibiotic prophylaxis or placebo, before a dental procedure in people with an increased risk of bacterial endocarditis. Cohort studies would need to follow at-risk individuals and assess outcomes following any invasive dental procedures, grouping participants according to whether or not they had received prophylaxis. Case-control studies would need to match people who had developed endocarditis after undergoing an invasive dental procedure (and who were known to be at increased risk before undergoing the procedure) with those at similar risk who had not developed endocarditis.  Our outcomes of interest were mortality or serious adverse events requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse effects of the antibiotics; and the cost of antibiotic provision compared to that of caring for patients who developed endocarditis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search records, selected studies for inclusion, assessed the risk of bias in the included study and extracted data from the included study. As an author team, we judged the certainty of the evidence identified for the main comparison and key outcomes using GRADE criteria. We presented the main results in a summary of findings table.

MAIN RESULTS

Our new search did not find any new studies for inclusion since the last version of the review in 2013. No randomised controlled trials (RCTs), controlled clinical trials (CCTs) or cohort studies were included in the previous versions of the review, but one case-control study met the inclusion criteria. The trial authors collected information on 48 people who had contracted bacterial endocarditis over a specific two-year period and had undergone a medical or dental procedure with an indication for prophylaxis within the past 180 days. These people were matched to a similar group of people who had not contracted bacterial endocarditis. All study participants had undergone an invasive medical or dental procedure. The two groups were compared to establish whether those who had received preventive antibiotics (penicillin) were less likely to have developed endocarditis. The authors found no significant effect of penicillin prophylaxis on the incidence of endocarditis. No data on other outcomes were reported. The level of certainty we have about the evidence is very low.

AUTHORS' CONCLUSIONS

There remains no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in at-risk people who are about to undergo an invasive dental procedure. We cannot determine whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically, practitioners should discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

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.

Clinical and echocardiographic characteristics associated with the development of infective endocarditis in patients with significant mitral stenosis

BACKGROUND

Infective endocarditis (IE) confers significant mortality and morbidity in patients with underlying mitral stenosis (MS), with both diseased native valves and after valvular procedures.

PURPOSE

We examined the clinical and echocardiographic parameters in association with the development of IE on patients with significant MS.

METHODS

A total of 478 consecutive patients with index echocardiographic diagnosis of significant mitral stenosis (mitral valve area <1.5 cm² ) were included. Patients were grouped into those with or without IE on at least 5 years of follow-up. Baseline clinical, echocardiographic profile and clinical outcomes were compared.

RESULTS

IE was observed in 4.4% (n = 21) of the cohort. These patients were younger (45.3 ± 14.6 vs. 53.2 ± 15.5 years, p = 0.022) at the time of MS diagnosis. NT-proBNP was higher in patients who developed IE (13529 ± 12230 vs. 4381 ± 5875 pg/ml, p < 0.001), with larger left atrial diameter (54.4 ± 10.1 vs. 49.9 ± 9.5 mm, p = 0.040) and elevated pulmonary artery systolic pressure (PASP, 62.3 ± 17.2 vs. 47.2 ± 16.5 mmHg, p = 0.026). There was no significant difference in terms of MS severity, other concomitant valvulopathies, or etiology (rheumatic or degenerative) of MS. Patients who smoked had higher incidence of IE (33.3% vs. 14.2%, log-rank 7.27, p = 0.007). After adjusting for age, valve procedure and PASP, patients who smoked remained at elevated risk of IE (adjusted hazards ratio 2.99, 95% confidence interval 1.18-7.56, p = 0.021).

CONCLUSION

IE occurs in a proportion of patients with MS. Smoking, younger age of diagnosis of MS as well as dilated left atria with elevated PASP may be associated with an elevated risk of this complication.

Demographic, cardiological, microbiologic, and dental profiles of Brazilian patients who developed oral bacteria-related endocarditis

OBJECTIVE

Infective endocarditis (IE) may cause devastating complications with high morbidity and mortality rates. The aim of the present study was to study the demographic, cardiological, microbiologic, and dental profiles of patients with oral bacteria-related IE.

STUDY DESIGN

We present a retrospective study of patients with oral bacteria-related IE treated at Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de Sao Paulo, Brazil, between January 2009 and December 2019.

RESULTS

Of the 100 patients included, 70% were male with a mean age of 45.4 years at diagnosis. The most affected sites were aortic and mitral valves, 60% in prosthetic heart valves, 34% in native valves, and 3% in pacemakers. The most common cause of valvular disease was rheumatic cardiopathy (51.9%), and the most frequent complications were valvular and perivalvular damage (26%). Streptococcus viridans was the most common species (96%), dental caries were present in 57% of the patients, 78% had tooth loss, 45% had apical periodontitis, and 77% were at high/moderate risk for periodontal disease.

CONCLUSION

Oral bacteria-related IE among Brazilians was predominant in the prosthetic heart valves of young male adults previously affected by rheumatic cardiopathy. Streptococcus viridans was the main cause of IE, which was linked to patients with a poor oral health status.

High Counts and Anthracene Degradation Ability of Streptococcus mutans and Veillonella parvula Isolated From the Oral Cavity of Cigarette Smokers and Non-smokers

The composition and metabolic functions of oral microbiota are affected by many factors including smoking leading to several health problems. Cigarette smoking is associated with changes in oral microbiota composition and function. However, it is not known if the depletion of certain bacterial genera and species is due to specific toxins in cigarette smoke, or indirectly due to competition for colonization with smoking-enriched bacteria. Therefore, the aim of this study was to determine the effect of cigarette smoking on the microbial prevalence and polycyclic aromatic hydrocarbons (PAHs) biodegradation of selected enriched and depleted oral bacteria from oral microbiota of smokers compared to that in non-smokers. Samples of oral rinse from smokers and non-smokers were collected (n = 23, 12 smokers and 11 non-smokers) and screened for oral bacterial strains of Streptococcus mutans, Lactobacillus spp., and Veillonella spp. Comparing counts, S. mutans, V. tobetsuensis, and V. dispar showed higher counts in smokers compared to non-smokers while the Lactobacillus spp. were higher in non-smokers. Lactobacillus fermentum was prevalent in smokers, representing 91.67% of the total Lactobacillus spp. isolates. The biodegradation potential of anthracene; a representative of PAHs of collected isolates, in single and mixed cultures, was assayed with anthracene as the sole source of carbon using 2,6-dichlorophenol indophenol (2,6-DCPIP) as indicator. S. mutans isolates recovered from smokers showed higher degradation of anthracene compared to those recovered from non-smokers. The anaerobic anthracene biodegradation activity of V. parvula isolates from non-smokers was the highest among all isolates of the three recovered genera from the same subject. The anthracene biodegradation potential of Lactobacillus spp. was variable. Combinations of isolated bacteria in co-cultures showed that Lactobacillus spp. interfered with anthracene biodegradation ability along with the viable counts of S. mutans and Veillonella spp. In conclusion, oral dysbiosis due to cigarette smoking was observed not only due to changes in oral bacterial relative abundance but also extended to bacterial functions such as anthracene biodegradation tested in this study. Microbe-microbe interactions changed the anthracene biodegradation potential and growth of the microbial mixture compared to their corresponding single isolates, and these changes differ according to the constituting bacteria.

Comparison of clinical characteristics and outcomes of infective endocarditis between haemodialysis and non-haemodialysis patients in China

Objective

To clarify differences in clinical characteristics and outcomes between patients with infective endocarditis (IE) receiving long-term haemodialysis (HD group) and those not receiving haemodialysis (non-HD group).

Methods

Medical records of patients with IE, admitted to hospital between January 2010 and December 2017, were retrospectively studied. Clinical characteristics and outcomes were compared between HD and non-HD groups. Risk factors for IE were assessed by COX regression.

Results

Twenty-one HD and 143 non-HD patients were included. Predisposing heart conditions were more frequently observed in the non-HD versus HD group (90.9% versus 19.0%). Inappropriate antibiotic therapy rate before admission and proportion of methicillin-resistant Staphylococcus aureus and Enterococcus-associated IE was higher in the HD versus non-HD group. In the HD group, fewer patients underwent heart surgery (9.5% versus 51.7%), all-cause in-hospital mortality was higher (52.4% versus 21%), and survival rate was lower versus the non-HD group. COX regression analysis revealed that haemodialysis, use of central venous catheter (CVC) and inappropriate antibiotic therapy before admission increased IE mortality, while surgery improved long-term prognosis.

Conclusions

Haemodialysis patients with IE may have higher mortality and lower survival rates than patients with IE not receiving haemodialysis. Haemodialysis, use of CVC and inappropriate antibiotic therapy before admission may increase IE mortality. Surgery may improve long-term prognosis.

In-Hospital and Long-Term Outcomes of Infective Endocarditis in Chronic Dialysis Patients

Purpose

To elucidate the in-hospital and long-term outcomes of infective endocarditis (IE) in end-stage kidney disease (ESKD) patients on chronic dialysis and to analyze the risk factors of mortality.

Patients and Methods

The case files of 1,817 patients who were hospitalized for IE over a 14-year period were retrospectively reviewed. Of these, 116 ESKD patients on chronic dialysis were enrolled in this study. Cox’s proportional hazard model was used to evaluate the risk factors of mortality and long-term outcomes.

Results

The in-hospital mortality rate of the 116 enrolled patients was as high as 43.1%. Patients who survived the index admission had a three-year mortality rate of 33%. Univariate analysis was used to compare survivors and non-survivors; poor in-hospital outcomes were associated with the use of a tunneled cuffed catheter for dialysis access, a shorter duration hospitalization, shock or respiratory failure during hospitalization, a higher white blood count, a higher percentage of polymorphonuclear leukocytes, a higher C-reactive protein level, a lower serum albumin level, and a higher total bilirubin level. Following multivariate adjustment, shock (odds ratio, 9.29, with a 95% confidence interval [CI] of 2.78 to 34.24; p<0.001) or respiratory failure (odds ratio, 25.16, with a 95% CI of 5.63 to 153.54; p<0.001) during hospitalization was strongly associated with increased in-hospital mortality. Patients who underwent cardiac operations (odds ratio, 0.22, with a 95% CI of 0.052 to 0.86; p=0.031) had better in-hospital outcomes. Heart failure reduced ejection fraction (HFrEF) at the time of initial hospitalization was an independent risk factor for 3-year mortality (hazard ratio, 3.48, with a 95% CI of 1.09 to 11.09; p=0.035).

Conclusion

The outcomes of IE for ESKD patients on chronic dialysis were poor. Only 56.9% of these patients survived the index admission and their mortality rate over three years was 33%. Shock or respiratory failure during hospitalization was associated with increased in-hospital mortality. Patients who underwent cardiac operations had better in-hospital outcomes. HFrEF at the time of initial hospitalization was an independent risk factor for three-year mortality.

[Antibiotic prophylaxis for infective endocarditis: current approaches]

This review addresses current views on prevention of infectious endocarditis (IE). History of establishing the concept of antibacterial prophylaxis (ABP), major approaches, and substantiation of changes in ABP in recent years are described. Recent international and national guidelines are highlighted, specifically, guidelines of the European Society of Cardiologists, American Heart Association/American College of Cardiology, and the Japanese Circulation Society. The review presents critical evaluation of previously approved international guidelines, including analysis of the effect of partial or complete ABP restriction on IE morbidity and incidence of complications. Special attention is paid to awareness of practitioners, particularly dentists, about ABP issues in their practice. Aspects of validity and key features of preventive approaches in implanting cardiac electronic devices and transcatheter aortic valve implantation are discussed.

Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Unsuspected Infective Endocarditis

OBJECTIVE

Infective endocarditis (IE) is considered to be an absolute contraindication for intravenous tissue plasminogen activator treatment (IVtPA) in acute ischemic stroke (AIS). However, during the hyperacute stroke evaluation, the exclusion of IE may be difficult. We sought to report the prevalence of undiagnosed IE in AIS patients who received IVtPA.

METHODS

We reviewed consecutive patients hospitalized at our comprehensive stroke center from January 1, 2014 to March 31, 2019 who received IVtPA for suspected AIS and identified patients diagnosed with IE. Data was abstracted on demographics, medical history, clinical presentation, last known normal (LKN) time, initial National Institutes of Health Stroke Scale (NIHSS), neuroimaging, culture results, and 90 day modified Rankin Scale (mRS). Good functional outcome was defined as mRS ≤ 2.

RESULTS

Among 1022 AIS patients who received IVtPA, 5 patients (0.5%) were ultimately diagnosed with IE. Among the 5 patients with IE, the mean age was 53.4 years (range, 25-74) and 3 (60%) were female. The majority 4 (80%) were white. Medical risk factors for IE were present in 3 (60%) and included intravenous drug use (1) and dialysis (2). Initial NIHSS was 4.6 (range, 1 to 8). Fever was present on initial presentation in only 1 patient (102.7 F). The mean time from LKN to IVtPA was 3.0 hours (range, 1.9 to 4.4). Vascular imaging showed middle cerebral artery (MCA) occlusion in 4 (80%) and no occlusion in 1 (20%). One patient underwent endovascular thrombectomy. Two patients (40%) developed hemorrhagic complications, including 1 patient who developed subarachnoid hemorrhage due to mycotic cerebral aneurysm rupture. Blood culture results included MRSE (1), Streptococcus viridans (2) and negative (2). TEE in all patients showed vegetations on the mitral valve. No patients had good functional outcomes, and the mean 3 month mRS was 4.8 (range, 3 to 6). The 90 day mortality was 60%.

CONCLUSION

In a series of AIS patients who received IVtPA by academic vascular neurologists, the risk of undiagnosed IE was low (0.5%). Fever was not commonly present during initial evaluation in IE presenting with AIS. Despite affecting younger patients with initial mild deficits, AIS patients with IE who received IVtPA had poor functional outcomes.

Native Mitral Valve Infective Endocarditis From Flossing: A Case Report and Emergency Department Management

Infective endocarditis (IE) is a rare, elusive disease, carrying a 10%-30% mortality. Requiring a high index of suspicion, IE affects damaged native valves and prosthetic valves. While there are a number of inherent risk factors that predispose patients to IE, dental work in the preceding six weeks is often a culprit of disease, colonizing damaged native mitral valves with Streptococcus viridans species. Traditionally, flossing has been suggested to be protective against IE. We present a case of S. gordonii subacute IE on a regurgitant native mitral valve secondary to vigorous flossing.

Analysis of the frequency of bacteraemia of dental origin implicated in infective endocarditis in patients requiring valve surgery

Understanding the frequency of bacteraemia of dental origin that is implicated in severe infective endocarditis (IE) will further our understanding of the disease's pathoaetiology and help us take steps to reduce its prevalence. A total of 78 patients from the Royal Papworth Hospital, Cambridge, who had valve surgery due to IE (as confirmed by the Modified Duke Criteria) were included. Case notes were retrospectively reviewed for microorganisms that were implicated in the bacteraemia and IE. Associated factors were also recorded to determine whether they were different if a dental or non-dental pathogen was inoculated. A dental pathogen was implicated in 24 of the patients with IE; 20 had non-dental pathogens, and 30 were culture negative. This was not deemed statistically significant (p=0.54). Of the associated factors, only smoking was statistically significant with a greater proportion of non-smokers having bacteraemia of dental origin (p=0.03). No other associated factor was appreciably different based on the aetiology of the microorganism. Our results indicate that dental pathogens are not more likely to cause severe IE. We therefore advocate the stance adopted by the current national guidance on the judicious prescription of antibiotic prophylaxis for IE with regard to dental procedures.

Infective Endocarditis and Its Short and Long-Term Prognosis in Hemodialysis Patients: A Systematic Review and Meta-analysis

There are some conclusive evidences on infective endocarditis and its poor prognosis in the background of end-stage renal disease in patients undergoing chronic hemodialysis; however the findings on the risk of infective endocarditis and its long-term prognosis are very diverse, requiring a systematic approach to achieve a global statistic. Our study tried to systematically assess the risk profile as well as short- and long-term prognosis of infective endocarditis among hemodialysis patients. To select our pointed studies, a deeply searching was planned among major articles databases including MEDLINE, Web of Science, SCOPUS, Google Scholar, and Cochrane Central Register of Controlled Trials considering the study keywords. Two high-qualified investigators independently assessed the collected papers. The risk of bias for the studies was also assessed according to the Cochrane's guideline and using the QUADAS-2 tool. In final, 18 articles were eligible for the final analysis. The overall prevalence of infective endocarditis among patients under chronic hemodialysis was estimated to be 2.9% (95% confidence interval [CI]: 2.7%-3.1%). Our assessment revealed an overall in-hospital death rate of 29.5% (95% CI: 26.7%-46.6%) and long-term death rate of 45.6% (95% CI: 41.9%-49.3%) in hemodialysis patients suffering infective endocarditis. Poor prognosis with high early and long-term death rates due to infective endocarditis has expected in the background of chronic hemodialysis emphasizing the necessity for its early management by identifying patients which prone to disease along with continuous cardiac monitoring.

Coagulation: At the heart of infective endocarditis

Infective endocarditis is a life-threatening and enigmatic disease with a mortality of 30% and a pathophysiology that is poorly understood. However, at its core, an endocarditis lesion is mainly a fibrin and platelet blood clot infested with bacteria, clinging at the cardiac valves. Infective endocarditis therefore serves as a paradigm of immunothrombosis gone wrong. Immunothrombosis refers to the entanglement of the coagulation system with innate immunity and the role of coagulation in the isolation and clearance of invading pathogens. However, in the case of infective endocarditis, instead of containing the infection, immunothrombosis inadvertently creates the optimal shelter from the immune system and allows some bacteria to grow almost unimpeded. In every step of the disease, the coagulation system is heavily involved. It mediates the initial adhesion of bacteria to the leaflets, fuels the growth and maturation of a vegetation, and facilitates complications such as embolization and valve destruction. In addition, the number one cause of infective endocarditis, Staphylococcus aureus, has proven to be a true manipulator of immunothrombosis and thrives in the fibrin rich environment of an endocarditis vegetation. Considering its central role in infective endocarditis, the coagulation system is an attractive therapeutic target for this deadly disease. There is, however, a very delicate balance at play and the use of antithrombotic drugs in patients with endocarditis is often accompanied with a high bleeding risk.

MitraClip-Associated Endocarditis: Emergency Department Diagnosis With Point of Care Ultrasound

BACKGROUND

Management of mitral valve regurgitation in patients with multiple comorbidities is complicated because of poor surgical candidacy. Less invasive techniques for these patients include the MitraClip device, an endovascular repair option used to reduce mitral valve regurgitation symptoms. However, complications include leaflet damage, stenosis, and infectious endocarditis.

CASE REPORT

Four years after MitraClip placement, an 80-year-old man presented to the emergency department with progressive dyspnea. He was diagnosed with MitraClip-associated infectious endocarditis by the emergency physician using point-of-care ultrasound. There are 6 reported cases of infective endocarditis in patients with MitraClip devices, with this being the first case identified using point-of-care ultrasound. This is also the first reported case of MitraClip-associated Corynebacterium endocarditis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The use of the MitraClip device and its echocardiographic appearance is not widely described in the published emergency medicine literature. Knowledge of this device, its appearance, and the potential complications is essential for emergency physicians caring for these patients. Rapid diagnosis may lead to earlier initiation of treatment and optimal disposition for these complex patients.

Incidence and factors associated with infective endocarditis in patients undergoing left-sided heart valve replacement

Aims

Patients with left-sided heart valve replacement are considered at high-risk of infective endocarditis (IE). However, data on the incidence and risk factors associated with IE are sparse.

Methods and results

Through Danish administrative registries, we identified patients who underwent left-sided heart valve replacement from January 1996 to December 2015. Patients were categorized in mitral and aortic valve replacement (MVR and AVR) and followed until: 12 years after valve surgery, end of study, death, emigration, or hospitalization due to IE, whichever came first. Multivariable adjusted Cox proportional hazard analysis was used to investigate which baseline characteristics were associated with IE. A total of 18 041 patients were included. The cumulative IE risk at 10 years follow-up was 5.2% in both MVR and AVR patients. In patients with MVR, male sex [hazard ratio (HR) = 1.68, 95% confidence interval (95% CI) 1.06-2.68], bioprosthetic valve (HR = 1.91, 95% CI 1.08-3.37), and heart failure (HR = 1.69, 95% CI 1.06-2.68) were among factors associated with an increased risk of IE. In AVR patients, male sex (HR = 1.59, 95% CI 1.33-1.89), bioprosthetic valve (HR = 1.70, 95% CI 1.35-2.15), and cardiac implantable electronic device (CIED) (HR = 1.57, 95% CI 1.19-2.06) were among factors associated with an increased risk of IE.

Conclusion

Infective endocarditis after left-sided heart valve replacement is not uncommon and occurs in about 1/20 over 10 years. Male, bioprosthetic valve, and heart failure were among factors associated with IE in MVR patients while male, bioprosthetic valve, and CIED were among factors associated with IE in AVR patients.

Infective endocarditis according to type 2 diabetes mellitus status: an observational study in Spain, 2001-2015

Background

The main aims of this study were to describe trends and outcomes during admission for infective endocarditis (IE) in people ≥ 40 years old with or without type 2 diabetes distributed in five time-periods (2001–2003; 2004–2006; 2007–2009; 2010–2012 and 2013–2015), using Spanish national hospital discharge data.

Methods

We estimated admission rates by diabetes status. We analyzed comorbidity, therapeutic procedures, and outcomes. We built Poisson regression models to compare the adjusted time-trends in admission rates. Type 2 diabetes cases were matched with controls using propensity score matching (PSM). We tested in-hospital mortality (IHM) in logistic regression analyses.

Results

We identified 16,626 hospitalizations in patients aged ≥ 40 years for IE in Spain, 2001–2015. The incidence of IE increased significantly from 6.0/100,000 per year to 13.1/100,000 per year (p < 0.001) in the population with type 2 diabetes, and from 3.9/100,000 per year to 5.5/100,000 per year (p < 0.001) in the population without diabetes, over the study period. The adjusted incidence of IE was 2.2-times higher among patients with diabetes than among those without diabetes (IRR = 2.2; 95% CI 2.1–2.3). People with type 2 diabetes less often underwent heart valve surgery than people without diabetes (13.9% vs. 17.3%; p < 0.001). Although IHM decreased significantly in both groups over time, it represented 20.8% of IE cases among diabetes patients and 19.9% among PSM matched controls (p = 0.337). Type 2 diabetes was not associated with a higher IHM in people admitted to the hospital for IE (OR = 1.1; 95% CI 0.9–1.2).

Conclusion

Incidence rates of IE in Spain, among those with and without T2DM, have increased during the period 2001–2015 with significantly higher incidence rates in the T2DM population. In our population based study and after PSM we found that T2DM was not a predictor of IHM in IE.

Risk Factors for Acute Rheumatic Fever: Literature Review and Protocol for a Case-Control Study in New Zealand

Acute rheumatic fever (ARF) and its sequela, rheumatic heart disease (RHD), have largely disappeared from high-income countries. However, in New Zealand (NZ), rates remain unacceptably high in indigenous Māori and Pacific populations. The goal of this study is to identify potentially modifiable risk factors for ARF to support effective disease prevention policies and programmes. A case-control design is used. Cases are those meeting the standard NZ case-definition for ARF, recruited within four weeks of hospitalisation for a first episode of ARF, aged less than 20 years, and residing in the North Island of NZ. This study aims to recruit at least 120 cases and 360 controls matched by age, ethnicity, gender, deprivation, district, and time period. For data collection, a comprehensive pre-tested questionnaire focussed on exposures during the four weeks prior to illness or interview will be used. Linked data include previous hospitalisations, dental records, and school characteristics. Specimen collection includes a throat swab (Group A Streptococcus), a nasal swab (Staphylococcus aureus), blood (vitamin D, ferritin, DNA for genetic testing, immune-profiling), and head hair (nicotine). A major strength of this study is its comprehensive focus covering organism, host and environmental factors. Having closely matched controls enables the examination of a wide range of specific environmental risk factors.

Risk factors for infective endocarditis following transcatheter pulmonary valve replacement in patients with congenital heart disease

OBJECTIVES

We sought to delineate the risk factors for infective endocarditis (IE) in patients undergoing transcatheter pulmonary valve replacement (TCPVR).

BACKGROUND

Despite the therapeutic benefits of TCPVR for treatment of dysfunctional right ventricular outflow tracts, IE is a major complication of the approach. Specific hemodynamic gradients and patient immune status as predisposing factors for IE are largely unexplored.

METHODS

We performed a retrospective review of patients who had undergone TCPVR at UCLA between October 2010 and October 2017. Cases of IE were diagnosed based on the modified Duke criteria.

RESULTS

Two hundred and thirty-five cases of TCPVR were performed with a mean follow-up of 2.6 years (range 0.0-8.0 years). Sixteen distinct IE events developed in 13 patients (Melody™ n = 12, SAPIEN n = 1), with a median time from implant to IE of 3.3 years (range 2.0-7.2 years). Univariate Cox regression showed that immunocompromised status was significantly associated with the development of IE hazard ratios (HR 5.43 [1.80-16.4], p = .003). Kaplan-Meier curves show that the 5-year freedom from IE among immunocompetent patients was 87% (95% CI 78-96%) versus 64% (95% CI 39-89%) among immunocompromised patients (log-rank p = .02). Postimplant right ventricular systolic pressure was higher among immunocompromised patients (p = .03). The risk of IE post-TCPVR in immunocompromised patients with residual pulmonary stenosis was 43%.

CONCLUSIONS

Among the risk factors examined in this study, immunocompromised status was the most significant predictor of IE development post-TCPVR. Patients with the lowest risk of IE are those with competent immune systems, without a history of IE, and with minimal residual pulmonary valve gradients post-TCPVR.

Invasive Procedures Associated With the Development of Infective Endocarditis

BACKGROUND

Various invasive medical procedures might induce bacteremia and, hence, act as triggers for infective endocarditis. However, empirical data in humans on the potential dangers of invasive medical procedures in this regard are very sparse. Due to lack of sufficient data, it is currently debated whether the risk for endocarditis with medical procedures is substantial or rather negligible.

OBJECTIVES

The purpose of this nationwide case-crossover study was to quantify the excess risk for infective endocarditis in association with invasive medical and surgical procedures.

METHODS

The authors identified all adult patients treated for endocarditis in hospitals in Sweden between January 1, 1998, and December 31, 2011. The authors applied a case-crossover design and compared the occurrence of invasive medical procedures 12 weeks before endocarditis with a corresponding 12-week time period exactly 1 year earlier. The authors considered all invasive nondental medical procedures except for those that are likely to be undertaken due to endocarditis or sepsis or due to infections that could possibly lead to endocarditis.

RESULTS

The authors identified 7,013 cases of infective endocarditis during the study period. Among others, several cardiovascular procedures, especially coronary artery bypass grafting; procedures of the skin and management of wounds; transfusion; dialysis; bone marrow puncture; and some endoscopies, particularly bronchoscopy, were strongly associated with an increased risk for infective endocarditis.

CONCLUSIONS

This study suggests that several invasive nondental medical procedures are associated with a markedly increased risk for infective endocarditis.

Cardiac valve replacement for infective endocarditis in patients with end stage renal disease on hemodialysis - A single institution experience

Objective

To review outcomes in hemodialysis-dependent patients requiring cardiac valve replacement for infective endocarditis.

Methods

A retrospective chart review was conducted to identify all patients who underwent valve replacement within a six-year period (January 2009–December 2014). Inclusion criteria included a diagnosis of infective endocarditis and end stage renal disease on hemodialysis. Relevant clinical information including demographics, comorbidities, valve involvement, causative organisms, and type of hemodialysis access (arteriovenous fistula, arteriovenous graft, or tunneled catheter) was collected.

Results

A total of 1497 patients underwent cardiac valve replacement within the six-year period. Of these, 167 patients (11.2%) had infective endocarditis and 119 patients (7.9%) had end stage renal disease on hemodialysis. Overall 30-day mortality for valve replacement was 5.0% (75/1497). Mortality for patients with infective endocarditis was 7.2% (12/167) and for patients with end stage renal disease on hemodialysis was 10.1% (12/119). Thirty-three patients (2.2%) had infective endocarditis and end stage renal disease on hemodialysis. Of these, 12 patients were being dialyzed via arteriovenous fistula, 4 via arteriovenous graft, and 17 via tunneled catheter. Mortality occurred in 2 of 12 patients with arteriovenous fistula, 1 of 4 patients with arteriovenous graft, and 2 of 17 patients with tunneled catheter for an overall mortality of 15.2% (5/33).

Conclusion

Infective endocarditis remains a significant problem in patients with end stage renal disease on hemodialysis, particularly when tunneled catheters are utilized for hemodialysis access. Although appropriate algorithms have been developed to minimize long term use of tunneled catheters, bacteremia remains a significant problem. We reviewed our institutional experience and the medical literature to determine outcomes in hemodialysis-dependent patients with infective endocarditis requiring valve replacement. Despite mortality rates between 42 and 73% reported in the literature, our mortality rate was 15.2%. 1 Care of these critically ill patients must emphasize early diagnosis and aggressive management to optimize outcomes.

Acupuncture in Patients with Valvular Heart Disease and Prosthetic Valves

Endocarditis has been reported in patients with valvular heart disease who have undergone acupuncture treatment, although most have been associated with the use of semi-permanent needles. This has led reviewers to suggest that acupuncture may not only be contraindicated in such patients but that prophylactic antibiotics should be given.

This study investigated the use of acupuncture treatment in patients with proven valvular heart disease and observed whether endocarditis developed in such patients. All patients in a single-handed GP practice with proven valvular heart disease, including those with prosthetic valves, were identified over a ten-year period. Those who had undergone acupuncture treatment underwent a clinical examination and diagnostic tests, which focused on the signs, symptoms and laboratory criteria for the diagnosis of endocarditis and included a transthoracic echocardiogram. Autopsy findings were reviewed in any patient who died.

Based on these clinical and laboratory data, using the modified Duke's criteria for the diagnosis of endocarditis, patients were identified as having definite or possible endocarditis, or the diagnosis was rejected.

All patients underwent brief acupuncture with no skin disinfectant and no prophylactic antibiotics were given. Semi-permanent needles were avoided. Thirty-six patients with valvular heart disease underwent a total of 479 acupuncture treatments over a ten-year period. The median number of treatments was 9 (range 1 – 72), with a follow-up after treatment of 5.75 years (range 0.5 – 10 years). Definite endocarditis was not found in any patient, but two patients had possible endocarditis, eventually discounted by both negative blood cultures and echocardiography.

In conclusion, brief acupuncture was safe in this small cohort of valvular heart disease patients and no case of endocarditis was detected over a ten-year period.

Methicillin-Resistant Staphylococcus aureus Endocarditis from a Diabetic Foot Ulcer Understanding and Mitigating the Risk

Diabetic foot infections are a common cause of morbidity and mortality in the United States, and successful treatment often requires an aggressive and prolonged approach. Recent work has elucidated the importance of appropriate therapy for a given severity of diabetic foot infection, and highlighted the ongoing risk such patients have for subsequent invasive life-threatening infection should diabetic foot ulcers fail to heal. The authors describe the case of a man with diabetes who had prolonged, delayed healing of a diabetic foot ulcer. The ulcer subsequently became infected by methicillin-resistant Staphylococcus aureus (MRSA). The infection was treated conservatively with oral therapy and minimal debridement. Several months later, he experienced MRSA bloodstream infection and complicating endocarditis. The case highlights the ongoing risk faced by patients when diabetic foot ulcers do not heal promptly, and emphasizes the need for aggressive therapy to promote rapid healing and eradication of MRSA.

Duration and complications of diabetes mellitus and the associated risk of infective endocarditis

BACKGROUND

Long duration of diabetes mellitus (DM) is associated with an increased risk of infection, however no studies have yet focused on the duration of DM and the associated risk of infective endocarditis (IE).

METHODS

Patients with DM were identified through the Danish Prescription Registry, 1996-2015. Duration of DM was split in follow-up periods of: 0-5 years, 5-10 years, 10-15 years, and >15 years. Multivariable adjusted Poisson regression was used to calculate incidence rate ratios (IRR) according to study groups. DM late-stage complications and the associated risk of IE were investigated as time-varying covariates using the validated Diabetes Complications Severity Index (DCSI).

RESULTS

We included 299,551 patients with DM. In patients with DM duration of 0-5 years, 5-10 years, 10-15 years, and >15 years, the incidence rates of IE were 0.24, 0.33, 0.58, and 0.96 cases of IE/1000 person years, respectively. Patients with DM duration 5-10 years, 10-15 years, and >15 years were associated with a higher risk of IE with an IRR of 1.24 (95% CI: 1.02-1.51), 1.92 (95% CI: 1.52-2.43) and 3.05 (95% CI: 2.11-4.40), respectively, compared with DM duration 0-5 years. Patients with a DCSI score of 2, 3 and >3 were associated with a higher risk of IE compared with patients with a DCSI score of 0, IRR = 1.78 (95% CI: 1.34-2.36), IRR = 2.34 (95% CI: 1.73-3.16), and IRR = 2.59 (95% CI: 1.92-3.48), respectively.

CONCLUSION

This study shows a stepwise increase in the risk of IE with DM duration and severity independent of age and known comorbidity.

Management Considerations in Infective Endocarditis: A Review

IMPORTANCE

Infective endocarditis occurs in approximately 15 of 100 000 people in the United States and has increased in incidence. Clinicians must make treatment decisions with respect to prophylaxis, surgical management, specific antibiotics, and the length of treatment in the setting of emerging, sometimes inconclusive clinical research findings.

OBSERVATIONS

Community-associated infective endocarditis remains the predominant form of the disease; however, health care accounts for one-third of cases in high-income countries. As medical interventions are increasingly performed on older patients, the disease incidence from cardiac implanted electronic devices is also increasing. In addition, younger patients involved with intravenous drug use has increased in the past decade and with it the proportion of US hospitalization has increased to more than 10%. These epidemiological factors have led to Staphylococcus aureus being the most common cause in high-income countries, accounting for up to 40% of cases. The mainstays of diagnosis are still echocardiography and blood cultures. Adjunctive imaging such as cardiac computed tomographic and nuclear imaging can improve the sensitivity for diagnosis when echocardiography is not conclusive. Serological studies, histopathology, and polymerase chain reaction assays have distinct roles in the diagnosis of infective endocarditis when blood culture have tested negative with the highest yield obtained from serological studies. Increasing antibiotic resistance, particularly to S aureus, has led to a need for different antibiotic treatment options such as newer antibiotics and combination therapy regimens. Surgery can confer a survival benefit to patients with major complications; however, the decision to pursue surgery must balance the risks and benefits of operations in these frequently high-risk patients.

CONCLUSIONS AND RELEVANCE

The epidemiology and management of infective endocarditis are continually changing. Guidelines provide specific recommendations about management; however, careful attention to individual patient characteristics, pathogen, and risk of sequela must be considered when making therapeutic decisions.

Impact of AHA's 2007 guideline change on incidence of infective endocarditis in infants and children

Use a nationally representative sample to assess impacts of new clinical guidelines issued by the American Heart Association (AHA) in 2007 for many types of invasive procedures, with recommendations for significant decreases in antimicrobial prophylaxis use.

STUDY DESIGN

Interrupted time series analyses of pediatric hospitalizations for Infective Endocarditis (IE), using the Nationwide Inpatient Sample (NIS) ICD-9-CM diagnostic codes, identified IE hospitalizations for patients <18 years old from 2001 to 2012. Changes in IE incidence before and after 2007 AHA guidelines were evaluated, with differences in IE clinical severity assessed using in-hospital mortality and length of stay. Analyses were stratified by pathogen type and age group (0-9 y/o and 10-17 y/o).

RESULTS

With 3,748 patients in the study, we observed rising trends in IE incidence, but no significant difference between pre- and post-guideline. There was a significant trend increase for IE due to viridans group streptococci (VGS) for ages >10 years old, comparing pre-guideline to post-guideline periods, but not in children 0-9 years of age. Neither in-hospital mortality nor length of stay changed significantly during study.

CONCLUSIONS

The data did not demonstrate an impact of the 2007 guideline changes on overall incidence of pediatric IE. However, a significant increase in disease incidence trend due to VGS was observed for the 10-17 year-old group, compared pre- and post-guideline.

Oral Streptococcal Endocarditis, Oral Hygiene Habits, and Recent Dental Procedures: A Case-Control Study

BACKGROUND.

We aimed to compare oral hygiene habits, orodental status, and dental procedures in patients with infective endocarditis (IE) according to whether the IE-causing microorganism originated in the oral cavity.

METHODS.

We conducted an assessor-blinded case-control study in 6 French tertiary-care hospitals. Oral hygiene habits were recorded using a self-administered questionnaire. Orodental status was analyzed by trained dental practitioners blinded to the microorganism, using standardized clinical examination and dental panoramic tomography. History of dental procedures was obtained through patient and dentist interviews. Microorganisms were categorized as oral streptococci or nonoral pathogens using an expert-validated list kept confidential during the course of the study. Cases and controls had definite IE caused either by oral streptococci or nonoral pathogens, respectively. Participants were enrolled between May 2008 and January 2013.

RESULTS.

Cases (n = 73) were more likely than controls (n = 192) to be aged <65 years (odds ratio [OR], 2.85; 95% CI, 1.41-5.76), to be female (OR, 2.62; 95% CI, 1.20-5.74), to have native valve disease (OR, 2.44; 95% CI, 1.16-5.13), to use toothpicks, dental water jet, interdental brush, and/or dental floss (OR, 3.48; 95% CI, 1.30-9.32), and to have had dental procedures during the prior 3 months (OR, 3.31; 95% CI, 1.18-9.29), whereas they were less likely to brush teeth after meals. The presence of gingival inflammation, calculus, and infectious dental diseases did not significantly differ between groups.

CONCLUSIONS.

Patients with IE caused by oral streptococci differ from patients with IE caused by nonoral pathogens regarding background characteristics, oral hygiene habits, and recent dental procedures, but not current orodental status.

Comparison of the clinical features and outcomes of infective endocarditis between hemodialysis and non-hemodialysis patients

Hemodialysis (HD) patients are more susceptible to infective endocarditis (IE) due to the increased risk of bacterial invasion through intravascular access. However, it remains unclear whether the causative organisms and outcomes of IE in HD patients differ from those in non-HD patients. This study clarified the differences in clinical presentation and outcomes between HD and non-HD patients. At our hospital, we performed a retrospective study of 39 HD and 51 non-HD patients with echocardiography-confirmed IE between June 2000 and February 2007. No differences in sex, intravenous drug use, previous diagnosis of congestive heart failure, and previous valvular surgery were observed between these two groups. The number of patients with diabetic mellitus in these two groups was significantly different (28.2% HD vs 5.9% non-HD patients). The C-reactive protein levels in the two groups were not significantly different. By contrast, the erythrocyte sedimentation rate was significantly higher in the HD patients (HD vs non-HD: 87.2±33.32 vs 52.96±28.19). The incidence of IE involving the mitral valve (MV; 45.1%) or the aortic valve (AV; 43.1%) was similar among the non-HD patients, whereas a preference of IE involving the MV (79.5%) over the AV (15.4%) was noted among the HD patients. The HD patients had a significantly higher Staphylococcus aureus infection rate (HD: 46.2%; non-HD: 27.5%). The proportion of methicillin-resistant S. aureus (MRSA; 83.8%) infection accounting for S. aureus IE in the HD group was higher than that (28.6%) in the non-HD group. The in-hospital mortality rate did not differ between the two groups. In conclusion, compared with non-HD patients, a propensity of IE involving the MV and a higher MRSA infection rate were observed in HD patients. The in-hospital mortality rate of echocardiography-confirmed IE did not differ between the two groups.

Nephrologists Hate the Dialysis Catheters: A Systemic Review of Dialysis Catheter Associated Infective Endocarditis

A 53-year-old Egyptian female with end stage renal disease, one month after start of hemodialysis via an internal jugular catheter, presented with fever and shortness of breath. She developed desquamating vesiculobullous lesions, widespread on her body. She was in profound septic shock and broad spectrum antibiotics were started with appropriate fluid replenishment. An echocardiogram revealed bulky leaflets of the mitral valve with a highly mobile vegetation about 2.3 cm long attached to the anterior leaflet. CT scan of the chest, abdomen, and pelvis showed bilateral pleural effusions in the chest, with triangular opacities in the lungs suggestive of infarcts. There was splenomegaly with triangular hypodensities consistent with splenic infarcts. Blood cultures repeatedly grew Candida albicans. Despite parenteral antifungal therapy, the patient deteriorated over the course of 5 days. She died due to a subsequent cardiac arrest. Systemic review of literature revealed that the rate of infection varies amongst the various types of accesses, and it is well documented that AV fistulas have a much less rate of infection in comparison to temporary catheters. All dialysis units should strive to make a multidisciplinary effort to have a referral process early on, for access creation, and to avoid catheters associated morbidity.

Results of Isolated Valve Replacement in Hemodialysis Patients

Frequent bleeding complications and poor long-term results have been reported after valve replacement in hemodialysis patients. We use mainly bileaflet mechanical valves with low-dose warfarin therapy (target international normalized ratio, 1.8–2.0) in such cases. Data of 27 hemodialysis patients undergoing isolated valve replacement from 1993 to 2002 were retrospectively analyzed. Bileaflet mechanical valves were selected in 23 patients and bioprostheses in 4. Those with mechanical valves were treated with mild anticoagulation therapy. There were 3 (11.1%) early deaths due to ischemic colitis, interstitial pneumonia, and ventricular arrhythmia. There were 3 late deaths and 5 bleeding complications during follow-up. The overall survival rate was 85.2% at 3 years and 72.9% at 5 years. The survival rate of patients with mechanical valves was 82.6% at 3 years and 76.7% at 5 years. One patient with a bioprosthesis experienced structural valvular deterioration after 3 years. The results demonstrate an acceptable long-term outcome. A bileaflet mechanical valve managed with mild anticoagulation therapy is a reasonable strategy for hemodialysis patients.

Apigenin reduce lipoteichoic acid-induced inflammatory response in rat cardiomyoblast cells

Infective endocarditis is caused by Streptococcus sanguinis present in dental plaque, which can induce inflammatory responses in the endocardium. The present study depicts research on the properties of apigenin in embryonic mouse heart cells (H9c2) treated with lipoteichoic acid (LTA) obtained from S. sanguinis. Interleukin-1β and cyclooxygenase (COX)-2 expression were detected by reverse transcriptase polymerase chain reaction. In addition, western blot assays and immuno-fluorescence staining were used to assess translocation of nuclear factor kappa beta (NF-κB), degradation of IκB, as well as activity of the mitogen activated protein kinases: extracellular signal-regulated kinase (ERK)1/2, p38, and c-Jun N-terminal kinase (JNK). Effect of apigenin on cell viability was equally assessed in other experimental series. Our results showed that apigenin blocked activation of ERK, JNK, and p38 in cardiomyocytes treated with LTA in a dose-dependent fashion. Moreover, apigenin showed no cytotoxic effects; it blocked NF-κB translocation and IκB degradation. Our findings suggested that apigenin possessed potential value in the treatment of infectious endocarditis.

Current features of infective endocarditis in persons on hemodialysis: a prevalence study with case control design from the prospective multicenter SEI cohort

PURPOSE

Persons on hemodialysis (HD) are at high risk of infective endocarditis (IE). In non-comparative retrospective studies, a higher rate of mortality was reported in IE on HD. We assessed risk factors, clinical characteristics, and outcomes of IE in HD.

METHODS

This was a prevalence study with a case control methodology on a set of data from the prospectively followed cohort of the Studio Endocarditi Italiano (SEI), conducted between 2004 and 2011. Included were 42 consecutive cases of IE HD subjects and 126 controls not on HD, matched for age, sex, type of IE, and heart side involved. Clinical, echocardiographic, microbiological features, and disease complications and therapeutic modalities were assessed.

RESULTS

HD patients were more often diabetics (42.9 vs 18.2 % in no-HD; p = 0.007) and immune-suppressed (16.7 vs 3.2 %; p = 0.02), and had a higher rate of predisposing cardiac conditions (45 vs 25 %; p = 0.031). A higher prevalence of health care-related acquisition and a shorter diagnostic delay was observed in IE on HD, that was more likely to be caused by staphylococci and less by streptococci (p < 0.002). Cardiac surgery was performed in 38 % of HD patients and 36.5 % of no-HD patients (p = 0.856). Complications were similar and in-hospital mortality did not differ significantly (26.2 % in HD vs 15.9 % in no-HD; p = 0.168).

CONCLUSIONS

IE in persons on HD is characterized by distinctive clinical features, including a higher prevalence of some important comorbidities. Inconsistent with prior studies, we could not confirm a higher rate of complications and mortality in HD patients with IE.

Dental Procedures and the Risk of Infective Endocarditis

Infective endocarditis (IE) is an uncommon but potentially devastating disease. Recently published data have revealed a significant increase in the incidence of IE following the restriction on indications for antibiotic prophylaxis as recommended by the revised guidelines. This study aims to reexamine the basic assumption behind the rationale of prophylaxis that dental procedures increase the risk of IE.Using the Longitudinal Health Insurance Database of Taiwan, we retrospectively analyzed a total of 739 patients hospitalized for IE between 1999 and 2012. A case-crossover design was conducted to compare the odds of exposure to dental procedures within 3 months preceding hospitalization with that during matched control periods when no IE developed.In the unadjusted model, the odds ratio (OR) was 0.93 for tooth extraction (95% confidence interval [CI] 0.54-1.59), 1.64 for surgery (95% CI 0.61-4.42), 0.92 for dental scaling (95% CI 0.59-1.42), 1.69 for periodontal treatment (95% CI 0.88-3.21), and 1.29 for endodontic treatment (95% CI 0.72-2.31). The association between dental procedures and the risk of IE remained insignificant after adjustment for antibiotic use, indicating that dental procedures did not increase the risk of IE.Therefore, this result may argue against the conventional assumption on which the recommended prophylaxis for IE is based.