Age-dependent profile of left-sided infective endocarditis: a 3-center experience

The Mortality of Infective endocarditis with and without Surgery in Elderly (MoISE) Study

BACKGROUND

Infective endocarditis (IE) is increasingly affecting older patients. However, data on their management are sparse, and the benefits of surgery in this population are unclear.

METHODS

We included patients with left-sided IE (LSIE) aged ≥ 80 years enrolled in a prospective endocarditis cohort managed in Aquitaine, France, from 2013 to 2020. Geriatric data were collected retrospectively to identify factors associated with the 1-year risk of death using Cox regression.

RESULTS

We included 163 patients with LSIE (median age, 84 years; men, 59%; rate of prosthetic LSIE, 45%). Of the 105 (64%) patients with potential surgical indications, 38 (36%) underwent valve surgery: they were younger, more likely to be men with aortic involvement, and had a lower Charlson comorbidity index. Moreover, they had better functional status at admission (ie, the ability to walk unassisted and a higher median activities of daily living [ADL] score; n = 5/6 vs 3/6, P = .01). The 1-year mortality rate in LSIE patients without surgical indications was 28%; it was lower in those who were operated on compared with those who were not despite a surgical indication (16% vs 66%, P < .001). Impaired functional status at admission was strongly associated with mortality regardless of surgical status. In patients unable to walk unassisted or with an ADL score <4, there was no significant surgical benefit for 1-year mortality.

CONCLUSIONS

Surgery improves the prognosis of older patients with LSIE and good functional status. Surgical futility should be discussed in patients with altered autonomy. The endocarditis team should include a geriatric specialist.

Contemporary Clinical Profile of Left-Sided Native Valve Infective Endocarditis: Influence of the Causative Microorganism

Studies focused on the clinical profile of native valve endocarditis are scarce and outdated. In addition, none of them analyzed differences depending on the causative microorganism. Our objectives are to describe the clinical profile at admission of patients with left-sided native valve infective endocarditis in a contemporary wide series of patients and to compare them among the most frequent etiologies. To do so, we conducted a prospective, observational cohort study including 569 patients with native left-sided endocarditis enrolled from 2006 to 2019. We describe the modes of presentation and the symptoms and signs at admission of these patients and compare them among the five more frequent microbiological etiologies. Coagulase-negative Staphylococci and Enterococci endocarditis patients were the oldest (71 ± 11 years), and episodes caused by Streptococci viridans were less frequently nosocomial (4%). The neurologic, cutaneous or renal modes of presentation were more typical in Staphylococcus aureus endocarditis (28%, p = 0.002), the wasting syndrome of Streptococcus viridans (49%, p < 0.001), and the cardiac in Coagulase-negative Staphylococci, Enterococci and unidentified microorganism endocarditis (45%, 49% and 56%, p < 0.001). The clinical signs agreed with the mode of presentation. In conclusion, the modes of presentation and the clinical picture at admission were tightly associated with the causative microorganism in patients with left-sided native valve endocarditis.

Temporal trends of mortality in patients with infective endocarditis: a nationwide study

AIMS

Little is known about the mortality for patients with infective endocarditis (IE) on a nationwide scale, and previous studies have been conducted in selected cohorts from tertiary centers. We aimed to investigate temporal trends in mortality using nationwide Danish registries.

METHODS AND RESULTS

We identified patients with first-time IE between 1999-2018, and they were grouped by calendar periods (1999-2003, 2004-2008, 2009-2013, 2014-2018). One-year mortality was estimated using Kaplan-Meier estimates. For calendar periods, odds ratios (ORs) and hazard ratios (HRs) were computed using multivariable adjusted logistic regression and Cox proportional Hazards analyses for in-hospital and one-year mortality, respectively. We identified 8804 patients with IE. Age and proportions of men were: 66.7 (25th-75th percentile: 53.4-76.7) years and 59.9% in 1999-2003 and 72.8 (25th-75th percentile: 63.4-80.3) and 65.8% in 2014-2018. In-hospital mortality was 1999-2003: 24.5%, 2004-2008: 22.8%, 2009-2013: 18.8%, and 2014-2018: 18.3%. Relative to 1999-2003, adjusted likelihoods of in-hospital mortality were: OR = 0.81 (95% CI: 0.69-0.96) in 2004-2008, OR = 0.59 (95% CI: 0.50-0.69) in 2009-2013, and OR = 0.51 (95% CI: 0.43-0.60) in 2014-2018. By calendar periods, crude risks of one-year mortality were: 34.4% (95% CI: 32.0-36.8%), 33.5% (95% CI: 31.5-35.6%), 32.1% (95% CI: 30.2-34.0%), and 33.1% (95% CI: 31.3-34.8%). Relative to 1999-2003, adjusted rates of one-year mortality were: HR = 0.88 (95% CI 0.79-0.99) in 2004-2008, HR = 0.76 (95% CI: 0.68-0.86) in 2009-2013, and HR = 0.72 (95% CI: 0.64-0.81) in 2014-2018.

CONCLUSION

In this nationwide study of patients with first-time IE between 1999-2018, both short- and long-term survival has improved over time when accounting for changes in patient characteristics.

ONE-SENTENCE SUMMARY

When accounting for patient characteristics, both short- and long-term mortality have improved in patients with first-time infective endocarditis.

Early Mortality Predictors in İnfective Endocarditis Patients: A Single-Center Surgical Experience

INTRODUCTION

Infective endocarditis is a disease that progresses with morbidity and mortality, afecting 3-10 out of 100,000 people per year. We conducted this study to review the early outcomes of surgical treatment of infective endocarditis.

METHODS

In this retrospective study, 122 patients who underwent cardiac surgery for infective endocarditis in our clinic between November 2009 and December 2020 were evaluated. Patients were divided into two groups according to in-hospital mortality. Demographic, echocardiographic, laboratory, operative, and postoperative data of the groups were compared.

RESULTS

Between November 3, 2009, and December 7, 2020, 122 patients were operated for infective endocarditis in our hospital. Emergency surgery was performed in nine (7.3%) patients. In-hospital mortality occurred in 23 (18.9%) patients, and 99 (81.1%) patients were discharged. In-hospital mortality was related with older age, presence of periannular abscess, New York Heart Association class 3 or 4 symptoms, low albumin level, high alanine aminotransferase level, and longer cross-clamping time (P<0.05 for all).

CONCLUSION

The presence of paravalvular abscess was the most important prognostic factor in patients operated for infective endocarditis.

Mid- and Long-Term Surgical Outcomes Due to Infective Endocarditis in Elderly Patients: A Retrospective Cohort Study

BACKGROUND

Infective endocarditis (IE) is one of the true remaining dreaded situations in cardiovascular medicine. Current international guidelines do not include specific recommendations for treatment options of infective endocarditis (conventional vs. surgical) based on the patient's age, functional status or comorbidities. Elderly patients have less invasive and often delayed surgeries compared to younger patients due to their shorter long-term survival probabilities. In the setting of IE, this might not be the right treatment, as surgery is the only curative option in up to 50% of all endocarditis patients. The aim of our study was to evaluate the mid- and long-term surgical outcomes due to infective endocarditis of patients aged ≥70 years.

METHODS

Between 2002 and 2020, a retrospective study with 137 patients aged 70 years and older and 276 patients aged below 70 years was conducted. Altogether, 413 consecutive patients who received surgery due to infective native or prosthetic valve endocarditis were assigned to either the elderly (E)-Group or the control (C)-Group. Primary endpoints were short- and long-term MACCEs (Major Adverse Cardiac and Cerebrovascular Events) as a composite of death or major adverse events, and secondary endpoints were intraoperative variables and postoperative course.

RESULTS

Preoperative risk factors differed significantly. Elderly patients had more arterial hypertension, atrial fibrillation, diabetes, chronic renal insufficiency and coronary heart disease. Fewer of them were in a state of emergency. Time from diagnosis to OR, antibiotic pretreatment, length of surgery and cardiopulmonary bypass time were significantly longer in the E-Group. Furthermore, 44.5% of patients in the E-Group had prosthesis endocarditis as opposed to 29.7% in the C-group. During postoperative follow-up, new onset of hemodialysis, duration of ventilation, delirium, reintubation and tracheotomy rates were significantly higher in the E-Group. There were significant differences in 7- and 30-day mortality. One- year survival was 62% for the E-Group and 79% for the C-Group. Five-year survival was 47% for the E-Group and 67% for the C-Group.

CONCLUSIONS

This study demonstrates that surgery for infective endocarditis is a high-risk procedure, especially for elderly people. Nevertheless, as it is more or less the only concept to increase long-term survival, it should be offered generously to all patients who are still able to take care of themselves.

Comorbidity and Prognosis in Octogenarians with Infective Endocarditis

Background. Infective endocarditis (IE) in older patients is associated with a high morbidity, mortality, and functional impairment. The purpose of this study was to describe the current profile of IE in octogenarians and to analyze the prognostic impact of baseline comorbidities in this population. Methods. Patients ≥ 80 years and definite IE from the Spanish IE Prospective Database were included. The effect of Charlson Comorbidity Index (CCI) on in-hospital and 12-month mortality was analyzed. Results. From 726 patients, 357 (49%) had CCI ≥ 3 and 369 (51%) CCI < 3. A total of 265 patients (36.6%) died during hospital admission and 338 (45.5%) during 1-year follow-up. CCI ≥ 3 was an independent predictor of in-hospital and 1-year mortality (odds ratio 1.46, 95% confidence interval 1.07−1.99, p = 0.017; hazard ratio 1.34, 95% confidence interval 1.08−1.66, p = 0.007, respectively). Surgical management was less common in patients with high comorbidity (CCI ≥ 3 68 [19.0%] vs. CCI < 3 112 ((30.4%) patients, p < 0.01). From 443 patients with surgical indication, surgery was only performed in 176 (39.7%). Patients with surgical indication treated conservatively had higher mortality than those treated with surgery (in-hospital mortality: 147 (55.1%) vs. 55 (31.3%), p < 0.001), (1-year mortality: 172 (64.4%) vs. 68 [38.6%], p < 0.001). Conclusion. About half of octogenarians with IE had high comorbidity with CCI ≥ 3. CCI ≥ 3 was a strong independent predictor of in-hospital and 1-year mortality. Our data suggest that the underperformance of cardiac surgery in this group of patients might have a role in their poor prognosis.

Infective Endocarditis in the Elderly: Challenges and Strategies

The specific management of infective endocarditis (IE) in elderly patients is not specifically addressed in recent guidelines despite its increasing incidence and high mortality in this population. The term "elderly" corresponds to different ages in the literature, but it is defined by considerable comorbidity and heterogeneity. Cancer incidence, specifically colorectal cancer, is increased in older patients with IE and impacts its outcome. Diagnosis of IE in elderly patients is challenging due to the atypical presentation of the disease and the lower performance of imaging studies. Enterococcal etiology is more frequent than in younger patients. Antibiotic treatment should prioritize diminishing adverse effects and drug interactions while maintaining the best efficacy, as surgical treatment is less commonly performed in this population due to the high surgical risk. The global assessment of elderly patients with IE, with particular attention to frailty and geriatric profiles, should be performed by multidisciplinary teams to improve disease management in this population.

Cardiac Imaging for Diagnosis and Management of Infective Endocarditis

Imaging is central to the care of patients with infective endocarditis. While transthoracic and transesophageal echocardiography are the principle imaging techniques, additional modalities including positron emission tomography and cardiac computed tomography, and to a lesser extent intracardiac echocardiography, play an increasing role. This review discusses the role of cardiac imaging in establishing the diagnosis of endocarditis, in predicting its embolic risk and in making decisions regarding the need for and timing of surgery.

Surgery and outcome of infective endocarditis in octogenarians: prospective data from the ESC EORP EURO-ENDO registry

PURPOSE

High mortality and a limited performance of valvular surgery are typical features of infective endocarditis (IE) in octogenarians, even though surgical treatment is a major determinant of a successful outcome in IE.

METHODS

Data from the prospective multicentre ESC EORP EURO-ENDO registry were used to assess the prognostic role of valvular surgery depending on age.

RESULTS

As compared to < 80 yo patients, ≥ 80 yo had lower rates of theoretical indication for valvular surgery (49.1% vs. 60.3%, p < 0.001), of surgery performed (37.0% vs. 75.5%, p < 0.001), and a higher in-hospital (25.9% vs. 15.8%, p < 0.001) and 1-year mortality (41.3% vs. 22.2%, p < 0.001). By multivariable analysis, age per se was not predictive of 1-year mortality, but lack of surgical procedures when indicated was strongly predictive (HR 2.98 [2.43-3.66]). By propensity analysis, 304 ≥ 80 yo were matched to 608 < 80 yo patients. Propensity analysis confirmed the lower rate of indication for valvular surgery (51.3% vs. 57.2%, p = 0.031) and of surgery performed (35.3% vs. 68.4%, p < 0.0001) in ≥ 80 yo. Overall mortality remained higher in ≥ 80 yo (in-hospital: HR 1.50[1.06-2.13], p = 0.0210; 1-yr: HR 1.58[1.21-2.05], p = 0.0006), but was not different from that of < 80 yo among those who had surgery (in-hospital: 19.7% vs. 20.0%, p = 0.4236; 1-year: 27.3% vs. 25.5%, p = 0.7176).

CONCLUSION

Although mortality rates are consistently higher in ≥ 80 yo patients than in < 80 yo patients in the general population, mortality of surgery in ≥ 80 yo is similar to < 80 yo after matching patients. These results confirm the importance of a better recognition of surgical indication and of an increased performance of surgery in ≥ 80 yo patients.

Reassessment of vegetation size as a sole indication for surgery in left-sided infective endocarditis

BACKGROUND

Guidelines recommend surgery in left-sided infective endocarditis (LSIE) associated with large vegetations. Given that most patients who undergo surgery also have other indications (heart failure and/or uncontrolled infection), it is not settled whether surgery should be routinely recommended in patients with large vegetations but no other predictors of poor outcome.

METHODS

A total of 726 patients with definitive LSIE were included in our analysis. Mean age was 64.9 years, 61% were male. Multivariate analysis of all patients was performed to determine if vegetation size is related to death in LSIE. Then, patients were divided in two groups according to vegetation size: Group A (>10 mm, n=420) and group B (≤10 mm, n=306). Univariate and multivariate analyses of group A patients were carried out to identify the variables related to death in this group. Impact of surgery on mortality of group A patients without heart failure or uncontrolled local infection (n=139) was assessed.

RESULTS

Age, Staphylococcus aureus, perivalvular complications, heart failure, kidney failure and septic shock, but not vegetation size, were associated with death. Patients with large vegetations showed increased mortality (31.7% in group A vs 24.8% in group B, p=0.045). Group A had more valve rupture and valve regurgitation than group B, but heart failure (55% vs 53%, p=0.678), stroke (22% vs 17.0%, p=0.091), systemic embolism (39% vs 32%, p=0.074), perivalvular complication (28% vs 28%, p=0.865) or septic shock (15% vs 13%, p=0.288) were similar in both groups. In patients from group A without heart failure or uncontrolled infection mortality was similar with and without surgery (n=139; n=70 with surgery, n=69 without surgery; mortality 18.6% vs 11.6% respectively, p=0.251).

CONCLUSIONS

large vegetations identify patients with poor outcome in LSIE. However, surgery is not associated with a better prognosis in patients with large vegetations if they do not present with another predictor of poor outcome such as heart failure or uncontrolled infection. These findings challenge whether vegetation size alone should be an indication for surgery in LSIE.

Global, regional, and national burden and quality of care index of endocarditis: the global burden of disease study 1990-2019

AIMS

Endocarditis accounts for significant morbidity and mortality. Timely diagnosis and prompt treatment are of paramount importance for optimal patient outcome. However, only few studies have assessed quality of care (QoC) in endocarditis. We aimed to describe QoC and changes in epidemiological features of endocarditis from 1990 to 2019.

METHODS AND RESULTS

Using primary indices of mortality, incidence, years of life lost, years lived with disability, and disability-adjusted life year, obtained from the Global Burden of Disease Study 2019, we calculated four secondary measures. Principal component analysis was performed to calculate QoC index (QCI), scored on a scale of 0-100 with higher values indicating better QoC, for different locations, age groups, and genders from 1990 to 2019. The all-ages incidence rate of endocarditis was estimated to increase significantly from 1990 to 2019, while mortality rate did not change. The age-standardized QCI was 73.6% globally, with higher values in high-income countries than in low-income countries. High-income North America (82.0%) and Asia Pacific (81.1%) had the highest QCI, whereas Eastern Europe (43.3%) had the lowest. Globally, the 30-49 and 95+ age groups had the highest (91.3%) and the lowest (71.7%) QCI, respectively. In most countries, particularly those with lower socio-demographic index, women had better QCI.

CONCLUSION

This is the first global assessment of QCI, shedding light on the current trends and highlighting the necessity of improving the endocarditis QoC, mainly by timely case detection, adherence to antibiotic prophylaxis guidelines, utilizing targeted antibiotics and advanced treatments, in the African region and resolving gender inequality in selected countries.

Surgery Is Underused in Elderly Patients With Left-Sided Infective Endocarditis: A Nationwide Registry Study

Background

Infective endocarditis is associated with higher mortality in elderly patients, but the role of surgery in this group has not been fully evaluated. The aim of this study was to assess outcomes of left‐sided infective endocarditis in elderly patients and to determine the influence of surgery on mortality in the elderly.

Methods and Results

A nationwide retrospective study was performed of 2186 patients with left‐sided infective endocarditis recorded in the SRIE (Swedish Registry of Infective Endocarditis), divided into patients aged <65 years (n=864), 65 to 79 years (n=806), and ≥80 years (n=516). Survival analysis was performed using the Swedish National Population Registry, and propensity score matching was applied to assess the effect of surgery on survival among patients of all ages. The rate of surgery decreased with increasing age, from 46% in the <65 group to 6% in the ≥80 group. In‐hospital mortality was 3 times higher in the ≥80 group compared with the <65 group (23% versus 7%) and almost twice that of the 65 to 79 group (12%). In propensity‐matched groups, the mortality rate was significantly lower between the ages of 55 and 82 years in patients who underwent surgery compared with patients who did not undergo surgery. Surgery was also associated with better long‐term survival in matched patients who were ≥75 years (hazard ratio, 0.36; 95% CI, 0.24–0.54 [P<0.001]).

Conclusions

The proportion of elderly patients with infective endocarditis who underwent surgery was low compared with that of younger patients. Surgery was associated with lower mortality irrespective of age. In matched elderly patients, long‐term mortality was higher in patients who did not undergo surgery, suggesting that surgery is underused in elderly patients.

Multimodality imaging in the diagnosis and management of prosthetic valve endocarditis: A contemporary narrative review

Infective endocarditis is one of the leading life-threatening infections around the world. With the exponential growth in the field of transcatheter interventions and advances in specialized surgical techniques, the number of prosthetic valves and cardiac implantable devices has significantly increased. This has led to a steep rise in the number of cases of prosthetic valve endocarditis (PVE) comprising up to 30% of all cases. Clinical guidelines rely on the use of the modified Duke criteria; however, the diagnostic sensitivity of the modified Duke criteria is reduced in the context of PVE. This is in part attributed to prosthesis related artifact which greatly affects the ability of echocardiography to detect early infective changes related to PVE in certain cases. There has been increasing recognition of the roles of complementary imaging modalities and updates in international society recommendations. Prompt diagnosis and treatment can prevent the devastating consequences of this condition. Imaging modalities such as cardiac computed tomography and ¹⁸-fluorodeoxyglucose positron emission tomography/computed tomography are diagnostic tools that provide a complementary role to echocardiography in aiding diagnosis, pre-operative planning, and treatment decision-making process in these challenging cases. Understanding the strengths and limitations of these adjuvant imaging modalities is crucial for the implementation of appropriate imaging modalities in clinical practice.

Surgical treatment for infective endocarditis in the ageing society: a nationwide retrospective study in Japan

Objective

The current status of surgical treatment for infective endocarditis (IE) among very elderly people is unclear.

Methods

We extracted data on patients in Japan with community-acquired IE who were admitted and discharged between April 2010 and February 2018 using a nationwide inpatient, the Diagnosis Procedure Combination database. We divided patients into three groups: non-elderly (<65 years), elderly (65–79 years) and very elderly (≥80 years). A 1:1 propensity score matching was performed to compare proportions of surgical treatment and in-hospital mortality among the groups.

Results

We identified 20 667 eligible patients (median age 70 years, 61.0% men). The proportion of very elderly patients significantly increased (19.1% in 2010 to 29.7% in 2018). The proportion of surgical treatment was significantly lower, and in-hospital mortality was significantly higher in very elderly patients. This tendency was more pronounced among patients with in-hospital complications such as heart failure, stroke or embolism. Surgical treatment was significantly associated with lower in-hospital mortality even in very elderly patients, both in an unmatched (OR 0.61; 95% CI 0.47 to 0.78) and a propensity score matched cohort (OR 0.61; 95% CI 0.43 to 0.85).

Conclusions

The proportion of very elderly patients with IE was increasing, and very elderly patients had higher in-hospital mortality. The proportion of surgical treatment for IE among very elderly patients was low, but it was associated with lower in-hospital mortality. Further studies are needed to establish the optimal strategy for IE among very elderly patients.

Predictive model of in-hospital mortality in left-sided infective endocarditis

INTRODUCTION AND OBJECTIVES

Infective endocarditis (IE) is a complex disease with high in-hospital mortality. Prognostic assessment is essential to select the most appropriate therapeutic approach; however, international IE guidelines do not provide objective assessment of the individual risk in each patient. We aimed to design a predictive model of in-hospital mortality in left-sided IE combining the prognostic variables proposed by the European guidelines.

METHODS

Two prospective cohorts of consecutive patients with left-sided IE were used. Cohort 1 (n=1002) was randomized in a 2:1 ratio to obtain 2 samples: an adjustment sample to derive the model (n=688), and a validation sample for internal validation (n=314). Cohort 2 (n=133) was used for external validation.

RESULTS

The model included age, prosthetic valve IE, comorbidities, heart failure, renal failure, septic shock, Staphylococcus aureus, fungi, periannular complications, ventricular dysfunction, and vegetations as independent predictors of in-hospital mortality. The model showed good discrimination (area under the ROC curve=0.855; 95%CI, 0.825-0.885) and calibration (P value in Hosmer-Lemeshow test=0.409), which were ratified in the internal (area under the ROC curve=0.823; 95%CI, 0.774-0.873) and external validations (area under the ROC curve=0.753; 95%CI, 0.659-0.847). For the internal validation sample (observed mortality: 29.9%) the model predicted an in-hospital mortality of 30.7% (95%CI, 27.7-33.7), and for the external validation cohort (observed mortality: 27.1%) the value was 26.4% (95%CI, 22.2-30.5).

CONCLUSIONS

A predictive model of in-hospital mortality in left-sided IE based on the prognostic variables proposed by the European Society of Cardiology IE guidelines has high discriminatory ability.

Infective endocarditis in elderly and very elderly patients

AIMS

To compare the clinical and epidemiological characteristics and the evolution of infective endocarditis in adults aged under 65 years, 65-79 years, and 80 years or older.

METHODS

An observational retrospective cohort study in patients with infective endocarditis was performed in a public hospital in Spain from January 2013 to December 2017.

RESULTS

Seventy-two patients were treated: 26 (36.1%) were under 65 years old, 28 (38.9%) were 65-79 years old, and 18 (25%) were aged 80 or older. Prosthetic valve endocarditis was less common in patients aged 65-79 years (3.6%) than in younger (23.1%; p = 0.047) or older (38.9%; p = 0.004) patients. In contrast, degenerative heart disease was more prevalent in the 65-79 year age group [64.3% compared to 15.4% (p < 0.001) in the youngest group, and 33.3% (p = 0.04) in the oldest]. Surgical interventions were similar in patients aged 65-79 (50%) and under 65 years (42.3%), but less common in people over 80 years (16.7%; p = 0.022).

CONCLUSIONS

The characteristics of infective endocarditis are different in patients aged 65-79 years and in those over 80 years.

How to manage patients in whom malignancy and infective endocarditis are associated: a review

Objective. Infective endocarditis (IE) is a potentially short-term lethal condition. An association with malignancy could complicate diagnostic and therapeutic decisions. The questions to be answered are: (1) which type of malignancies are encountered; (2) how often has the association between malignancy and IE been described, and (3) what are thus far the diagnostic and treatment strategies for patients with both conditions. Methods. A literature search from 2010 to 2018 has been performed with the focus on IE and cancer/malignancy/neoplasm, as well as with risk factors for adverse outcome, when cancer was included in the analysis. Results. An association between digestive, respiratory and hematologic malignancy with IE has been observed in four large databases. The most important mechanisms for this association are a "port of entry" and immune suppression. Sixteen studies dealt with the effect of short and mid-term cancer on the outcome of surgery of IE in these patients. No uniform management strategy could be identified. It seems that a malignancy does not alter the short-term outcome for IE, although referral to a tertiary cardiac center and surgical treatment are less common for patients with known malignancy. Conclusions. Although there is an association between malignancy and IE, no treatment strategy has yet been developed for these patients. Short-term outcome of IE is unaltered by cancer. In most papers, the effect of cancer on mid-term survival is only significant in a univariate analysis, without being a predictor. The results indicate that cardiac surgery for IE should not be withheld in patients in whom a treatable malignancy has been found.

Elderly versus non-elderly patients undergoing surgery for left-sided native valve infective endocarditis: A 10-year institutional experience

This retrospective study aimed to clarify the short- and mid-term outcomes of elderly patients who underwent surgery to treat left-sided native valve infective endocarditis (LSNIE). Between July 2005 and September 2015, 179 patients underwent surgical treatment for active LSNIE at a single institution. Patients were classified into two groups: ≥65 years (elderly group) and <65 years (non-elderly group). Clinical features, surgical information, postoperative complications, and three-year survival rates were compared. The average ages were 74.2 ± 6.4 and 45.2 ± 12.6 years in the elderly and non-elderly groups, respectively. The elderly group had a higher predicted mortality rate and a lower incidence of preoperative septic emboli-related complications. Echocardiographic assessments of infected valves were generally homogenous between the groups. The elderly patients had a higher in-hospital mortality rate than the non-elderly patients (26.3% vs. 5.7%, P = 0.001). For patients who survived to discharge, the three-year cumulative survival rates were 75.0% ± 8.2% and 81.2% ± 3.4% in the elderly and non-elderly groups, respectively (P = 0.484). In conclusion, elderly patients are at a higher risk of in-hospital mortality after surgery for LSNIE. However, once elderly patients are stabilized by surgical treatment and survive to discharge, the mid-term outcomes are promising.

The clinical features and prognosis of infective endocarditis in the elderly from 2007 to 2016 in a tertiary hospital in China

BACKGROUND

Infective endocarditis (IE) especially in the elderly is a serious disease, with a worse prognosis.

METHODS

A retrospective cohort study was conducted. A total of 405 patients with definite IE were divided into three groups: 205 patients under 50 years old, 141 patients between 50 and 64 years old and 59 patients over 65 years old.

RESULTS

For older patients, clinical symptoms such as fever, anemia, and heart murmur were as common as the younger patients. IE in old patients had more frequent nosocomial origin (P = 0.007) and tended to be more frequent with bad oral hygiene (p = 0.008). The most frequent isolated pathogens in the old groups was streptococci and coagulase-negative staphylococci. The old patients had a lower operation rate (40.7% vs 58.9% vs 62.4%, P = 0.012) and higher in-hospital mortality (20.3% vs 10.6% vs 8.8%, P = 0.044) compared with the younger patients. Surgical treatment was a significant predictor of one-year mortality even after adjusting for the confounders (HR = 2.45, 95% CI 1.027-10.598, P = 0.009). The one-year survival rate was higher for older patients with surgical intervention than those without (95.8% vs 68.6%, P = 0.007).

CONCLUSIONS

Older patients with IE presented with more comorbidities, bad oral hygiene, more nosocomial origin and a more severe prognosis than younger patients. Streptococci was the most frequent micro-organisms in this group. Surgery were underused in old patients and those with surgical treatment had better prognosis.

Clinical features and outcomes of infective endocarditis in Egypt: an 11-year experience at a tertiary care facility

BACKGROUND

Few data are available on the characteristics of infective endocarditis (IE) cases in Egypt. The aim of this work is to describe the characteristics and outcomes of IE patients and evaluate the temporal changes in IE diagnostic and therapeutic aspects over 11 years.

RESULTS

The IE registry included 398 patients referred to the Endocarditis Unit of a tertiary care facility with the diagnosis of possible or definite IE. Patients were recruited over two periods; period 1 (n = 237, 59.5%) from February 2005 to December 2011 and period 2 (n = 161, 40.5%) from January 2012 to September 2016. An electronic database was constructed to include information on patients' clinical and microbiological characteristics as well as complications and mortality. The median age was 30 years and rheumatic valvular heart disease was the commonest underlying cardiac disease (34.7%). Healthcare-associated IE affected 185 patients (46.5%) and 275 patients (69.1%) had negative blood cultures. The most common complications were heart failure (n = 148, 37.2%), peripheral embolization (n = 133, 33.4%), and severe sepsis (n = 100, 25.1%). In-hospital mortality occurred in 108 patients (27.1%). Period 2 was characterized by a higher prevalence of injection drug use-associated IE (15.5% vs. 7.2%, p = 0.008), a higher staphylococcal IE (50.0% vs. 35.7%, p = 0.038), lower complications (31.1% vs. 45.1%, p = 0.005), and a lower in-hospital mortality (19.9% vs. 32.1%, p = 0.007).

CONCLUSION

This Egyptian registry showed high rates of culture-negative IE, complications, and in-hospital mortality in a largely young population of patients. Improvements were noted in the rates of complications and mortality in the second half of the reporting period.

Role of age and comorbidities in mortality of patients with infective endocarditis

PURPOSE

The aim of this study was to analyse the characteristics of patients with IE in three groups of age and to assess the ability of age and the Charlson Comorbidity Index (CCI) to predict mortality.

METHODS

Prospective cohort study of all patients with IE included in the GAMES Spanish database between 2008 and 2015.Patients were stratified into three age groups:<65 years,65 to 80 years,and ≥ 80 years.The area under the receiver-operating characteristic (AUROC) curve was calculated to quantify the diagnostic accuracy of the CCI to predict mortality risk.

RESULTS

A total of 3120 patients with IE (1327 < 65 years;1291 65-80 years;502 ≥ 80 years) were enrolled.Fever and heart failure were the most common presentations of IE, with no differences among age groups.Patients ≥80 years who underwent surgery were significantly lower compared with other age groups (14.3%,65 years; 20.5%,65-79 years; 31.3%,≥80 years). In-hospital mortality was lower in the <65-year group (20.3%,<65 years;30.1%,65-79 years;34.7%,≥80 years;p < 0.001) as well as 1-year mortality (3.2%, <65 years; 5.5%, 65-80 years;7.6%,≥80 years; p = 0.003).Independent predictors of mortality were age ≥ 80 years (hazard ratio [HR]:2.78;95% confidence interval [CI]:2.32-3.34), CCI ≥ 3 (HR:1.62; 95% CI:1.39-1.88),and non-performed surgery (HR:1.64;95% CI:11.16-1.58).When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged <65 years(p < 0.001) for both in-hospital and 1-year mortality.

CONCLUSION

There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the <65-year group.

Comprehensive geriatric assessment in older patients suffering from infective endocarditis. A prospective multicentric cohort study

OBJECTIVES

The aim was to describe the impact of infective endocarditis (IE) on functional, cognitive and nutritional statuses, and to estimate the influence of these parameters on surgical management and mortality.

METHOD

This was a prospective study over 13 months in 14 French hospitals, including patients ≥75 years of age with definite or possible IE. A comprehensive geriatric assessment (CGA) was performed during the first week of hospitalization, including a retrospective estimation of functional status 2 months before hospitalization, and 3 months after.

RESULTS

A total of 120 patients were included (mean age 83.1 ± 5.0 (75-101) years). IE was associated with a dramatic impairment of functional status between 2 months prior hospitalization and the first geriatric evaluation (90.8% able to walk vs. 35.5% (p < 0.0001), ADL (Activities in Daily Living) 5.0 ± 1.7 vs. 3.1 ± 2.1 (p < 0.0001)). The 19 operated patients (15.8%) had less comorbidities (cumulative illness rating scale geriatric 10.8 ± 8.2 vs. 15.3 ± 7.1 (p 0.0176)), better functional (ADL 5.9 ± 0.4 vs. 4.9 ± 1.8 (p 0.0171) and nutritional (mini nutritional assessment 20.4 ± 5.0 vs. 17.3 ± 6.2 (p 0.0501)) statuses than non-operated patients. Among all infectious, cardiac and geriatric parameters, body mass index (HR 0.9, range 0.8-1, p 0.05) and ADL at the time of the first evaluation (HR 0.7, range 0.6-0.9, p 0.002) were the sole independent predictors of the 3-month (32.5%) and 1-year mortality (42.5%). Three months later, the 57 assessed patients only partially recovered their ADL (3.7 ± 1.9 vs. 5.3 ± 1.4 2 months prior hospitalization and 4.6 ± 1.9 at the first CGA; p < 0.0001).

CONCLUSION

Functional and nutritional abilities are crucial components that can be accurately explored through a CGA when managing IE in oldest patients.

Infective Endocarditis in the Elderly: Diagnostic and Treatment Options

Infective endocarditis (IE) is an uncommon, life-threatening systemic disorder with significant morbidity and persistently high mortality. The age of the peak incidence of IE has shifted from 45 years in the 1950s to 70 years at the present time, and elderly people have a five-fold higher risk of IE than the general adult population. Elderly IE patients demonstrate a higher prevalence of coagulase-negative staphylococci, enterococci and Streptococcus bovis, and lower rates of infection by viridans group streptococci. Methicillin resistance is more prevalent in elderly patients as a consequence of increased nosocomial acquisition. The elderly are a vulnerable group in whom diagnosis is often difficult on account of non-specific presenting features and where higher prevalence of comorbidities contributes to adverse outcomes. Treatment of older patients with IE presents specific challenges associated with prolonged antibiotic therapy, and access to surgery may be denied on account of advanced age and attendant comorbidities. This practical review covers all aspects of elderly IE, including clinical and microbiological diagnosis and appropriate diagnostic procedures, initial antibiotic selection, antibiotic prophylaxis, considerations about antibiotic therapy and surgery.

Surgery changes prognosis in infective endocarditis: The importance of post-surgical clinical evolution

BACKGROUND

Left-sided infective endocarditis (LSIE) bears a grim prognosis and surgery is needed in more than half of the patients to improve survival. Our hypothesis has been that clinical complications developing after surgery impact prognosis.

METHODS

Among 1075 consecutive episodes of LSIE, 654 (60.7%) underwent cardiac surgery. Of them, 41 patients (6.3%) died the same day of surgery, 112 (17.2%) died after the first day of surgery during hospital stay and 500 (76.5%) were successfully discharged. We compared the last two groups and performed a multivariable analysis of in-hospital mortality.

RESULTS

Age (OR 1.02, 95% CI 1.01-1.04), periannular complications (OR 1.9, 95% CI 1.2-3.2) renal failure after surgery (OR 2.4, 95% CI 1.3-4.4) but not before surgery, and septic shock after surgery (OR 9.6, 95% CI 5.4-17.1) but not before surgery are predictive of in-hospital death among LSIE patients who underwent cardiac surgery.

CONCLUSION

A thorough clinical assessment with prognostic purposes in infective endocarditis after surgery is mandatory. In-hospital mortality of patients with infective endocarditis who undergo surgery depends mainly on the clinical evolution after surgery.

[Infective endocarditis in the elderly: The current view of the problem]

The review gives the current views of the etiology and risk factors of infective endocarditis (IE) in the elderly. It reports the specific clinical picture of the disease at this age, including clinically apparent syndromes, comorbidity, and various clinical signs and peculiarities of IE. Particular emphasis is placed on the diagnosis of an endocardial infectious lesion, which is based on the use of the modified Duke criteria. The methods of IE diagnosis, particularly microbiological examination, imaging techniques, among which echocardiography in different modes plays a particular role, are listed. The treatment of the disease is based on the latest recommendations for antibiotic therapy with and without regard to a specific etiological factor. The issues of surgical intervention, as well as approaches to preventing IE in elderly people are discussed.

Observational Study of Infective Endocarditis at a Community-based Hospital: Dominance of Elderly Patients with Comorbidity

Objective The purpose of this study was to present the recent clinical profiles and the real-world management of infective endocarditis (IE). Methods All medical records of patients with IE were reviewed retrospectively for their clinical data, including clinical presentation, laboratory results, blood cultures, echocardiographic findings, treatments and complications. Using the clinical data collected, we calculated the EuroSCORE II, the European risk score for adult cardiac surgery, the Charlson Comorbidity Index as a surrogate of comordibity, and the Katz Index as a surrogate of frailty. Results Thirty-eight patients were identified as having IE (24 men, age: 71.8±13.1 years). Congestive heart failure occurred in 16 patients (42%), stroke in 14 (50%), and systemic embolism in 5 (13%). The EuroSCORE II and Charlson Comorbidity Index were high (7.7±5.8% and 5.5±2.8%, respectively). The Katz Index was fair (5.5±1.4) before the onset but deteriorated to 2.8±2.7 at the time of establishing the diagnosis of IE (p<0.001). Early surgery was performed in 22 cases (61%). In-hospital death occurred in 10 cases (26%). A EuroSCORE II ≥9%, Staphylococcus aureus etiology, and a Charlson Comorbidity Index were suggested as determinants of in-hospital death (hazard ratios: 173.60, 9.31, 1.57, respectively). In contrast, early surgery was suggested as a determinant of the survival (hazard ratio: 0.04). The Charlson Comorbidity Index was also suggested as a determinant for selecting conservative management (odds ratio: 1.40). Conclusion Comorbidity may influence the treatment selection and outcome of elderly patients with IE.

The Evolving Nature of Infective Endocarditis in Spain: A Population-Based Study (2003 to 2014)

BACKGROUND

Little information exists regarding population-based epidemiological changes in infective endocarditis (IE) in Europe.

OBJECTIVES

This study sought to analyze temporal trends in IE in Spain from 2003 to 2014.

METHODS

This retrospective, population-based, temporal trend study analyzed the incidence, epidemiological and clinical characteristics, and outcome of all patients discharged from hospitals included in the Spanish National Health System with a diagnosis of IE, from January 2003 to December 2014.

RESULTS

Overall, 16,867 episodes of IE were identified during the study period, 66.3% in men. The rate of IE significantly increased, from 2.72 in 2003 to 3.49 per 100,000 person-years in 2014, and this rise was higher among older adults. The most frequent microorganisms were staphylococci (28.7%), followed by streptococci (20.4%) and enterococci (13.1%). Twenty-three percent of patients underwent cardiac surgery. The in-hospital mortality rate was 20.4%. Throughout the study period, the proportion of patients with previously known heart valve disease and diabetes mellitus significantly increased, whereas the prevalence of intravenous drug use decreased. Regarding microorganisms, Staphylococcus aureus and streptococci slightly declined, whereas coagulase-negative staphylococci and enterococci consistently increased over the years. In-hospital complications and cardiac surgery rates significantly increased across the years. The risk-adjusted in-hospital mortality rate diminished (0.2% per year) during the study period.

CONCLUSIONS

The incidence of IE episodes significantly increased over the decade of the study period, particularly among older adults. Relevant changes in clinical and microbiological profile included older patients with more comorbidity and a rise in enterococci and coagulase-negative staphylococcal infections. Adjusted mortality rates slightly declined over the study period.

Long-term Evaluation of the Ross Procedure in Acute Infective Endocarditis

Optimal valve substitute for young patients with aortic valve endocarditis remains controversial. Given its better resistance to infection, the Ross procedure is an attractive alternative to prosthetic valve replacement or homograft implantation. The objective of this study was to assess long-term outcomes of the Ross procedure in this indication. From January 1991 to April 2017, 190 patients underwent a Ross procedure at our institution. Acute endocarditis was the indication for operation in 19 patients, including 6 patients with a bicuspid aortic valve. The pulmonary autograft was implanted as freestanding root replacement in all patients. The clinical follow-up is 100% complete, with a mean of 12.0 ± 5.7 years. The mean age of the study population was 35.9 ± 11.5 years. Moderate or severe aortic regurgitation was present in 84.2% of the patients. Systemic embolization had occurred in 36.8% of the patients. The mean aortic cross-clamp time was 126 ± 24 minutes. The median length of stay on the intensive care unit was 1 day. Mortality at 30 days was 5.3% (1 patient with gastrointestinal bleeding). Echocardiography at hospital discharge documented no or trivial aortic regurgitation in all patients. No case of recurrent endocarditis affecting the autograft occurred. One patient (0.4% per patient-year) was reoperated 1.8 years after the Ross procedure for homograft endocarditis. Three patients (15.8%) were reoperated for autograft aneurysm. The Ross procedure is a safe and effective alternative to prosthetic valve replacement or homograft implantation in selected young patients with acute endocarditis with a low rate of recurrent infection.

Infection in the Critically Ill Older Adult

Many challenges exist in caring for older adults with infection in critical care environments. Older adults are at high risk due to diminished reserve, age-related changes, comorbidities, subtle clinical presentations, and institutionalization. Additional risks include infections, such as pneumonia, influenza, and nosocomial infections. Age-related changes contribute to the increased risk of infection in older adults. Nursing assessments should be tailored to the needs of the older patient. To improve health care outcomes in this population, nursing care of the critically ill older adult with infection should include comprehensive assessment, surveillance for risks, and strategies aimed to aggressively treat infection.

Managing infective endocarditis in the elderly: new issues for an old disease

The incidence of infective endocarditis (IE) rises in industrialized countries. Older people are more affected by this severe disease, notably because of the increasing number of invasive procedures and intracardiac devices implanted in these patients. Peculiar clinical and echocardiographic features, microorganisms involved, and prognosis of IE in elderly have been underlined in several studies. Additionally, elderly population appears quite heterogeneous, from healthy people without past medical history to patients with multiple diseases or who are even bedridden. However, the management of IE in this population has been poorly explored, and international guidelines do not recommend adapting the therapeutic strategy to the patient's functional status and comorbidities. Yet, if IE should be treated according to current recommendations in the healthiest patients, concerns may rise for older patients who suffer from several chronic diseases, especially renal failure, and are on polypharmacy. Treating frailest patients with high-dose intravenous antibiotics during a prolonged hospital stay as recommended for younger patients could also expose them to functional decline and toxic effect. Likewise, the place of surgery according to the aging characteristics of each patient is unclear. The aim of this article is to review the recent data on epidemiology of IE and its peculiarities in the elderly. Then, its management and various therapeutic approaches that can be considered according to and beyond guidelines depending on patient comorbidities and frailty are discussed.

Polymicrobial Infective Endocarditis: Clinical Features and Prognosis

To describe the profile of left-sided polymicrobial endocarditis (PE) and to compare it with monomicrobial endocarditis (ME).Among 1011 episodes of left-sided endocarditis consecutively diagnosed in 3 tertiary centers, between January 1, 1996 and December 31, 2014, 60 were polymicrobial (5.9%), 821 monomicrobial (81.7%), and in 123 no microorganism was detected (12.2%). Seven patients (0.7%) were excluded from the analysis because contamination of biologic tissue could not be discarded. The authors described the clinical, microbiologic, echocardiographic, and outcome of patients with PE and compared it with ME.Mean age was 64 years SD 16 years, 67% were men and 30% nosocomial. Diabetes mellitus (35%) were the most frequent comorbidities, fever (67%) and heart failure (43%) the most common symptoms at admission. Prosthetic valves (50%) were the most frequent infection location and coagulase-negative Staphylococci (48%) and enterococci (37%) the leading etiologies. The most repeated combination was coagulase-negative Staphylococci with enterococci (n = 9). Polymicrobial endocarditis appeared more frequently in patients with underlying disease (70% versus 56%, P = 0.036), mostly diabetics (35% versus 24%, P = 0.044) with previous cardiac surgery (15% versus 8% P = 0.049) and prosthetic valves (50% versus 37%, P = 0.038). Coagulase-negative Staphylococci, enterococci, Gram-negative bacilli, anaerobes, and fungi were more frequent in PE. No differences on age, sex, symptoms, need of surgery, and in-hospital mortality were detected.Polymicrobial endocarditis represents 5.9% of episodes of left-sided endocarditis in our series. Despite relevant demographic and microbiologic differences between PE and ME, short-term outcome is similar.

Ross procedure is a safe treatment option for aortic valve endocarditis: Long-term follow-up of 42 patients

BACKGROUND

Aortic root replacement with a pulmonary autograft (Ross procedure) can be performed as a treatment of aortic valve endocarditis, avoiding prosthetic valve implantation in septic context. We sought to assess long-term outcomes of the Ross procedure in this indication.

METHODS

From April 1992 to March 2009, the intervention was performed in 42 patients (mean age 34 ± 8 years) suffering from an active or ancient aortic valve endocarditis. 36% of the patients had extensive perivalvular involvement, and surgery was urgent in 18 patients (43%). We performed a prospective clinical and echocardiographic follow-up of this population.

RESULTS

Median follow-up was 10 years (4-21 years). Overall survival at 10 and 15 years was respectively 87 ± 5% and 81 ± 8%. Perioperative mortality was 4.7% (2 patients) and no late cardiac death was reported. Eight patients (19%) underwent repeat surgery for autograft and/or homograft dysfunction at a median time of 8.4 years (3 months-18 years). Rate of recurrent endocarditis was low (7%-3 patients), including 1 in a context of persistent intravenous drug abuse. Clinical follow-up showed good functional status for all patients with NYHA ≤ II, and less than 25% of patients requiring cardiovascular medication. Late echocardiographic follow-up demonstrated well-functioning autograft and homograft, with only one severe aortic regurgitation, and one significant increase in pulmonary mean gradient.

CONCLUSION

The Ross procedure in aortic valve endocarditis is an interesting alternative to prosthetic valvular replacement in a selected population, with a high rate of survival free from any cardiovascular event or medication requirement.

Epidemiology and the prognosis of healthcare-associated infective endocarditis in China: the significance of non-nosocomial acquisition

Limited research has been conducted on healthcare-associated infective endocarditis (HAIE), although it is of increasing importance. The aim of this study is to compare the epidemiology, clinical characteristics, and prognosis of community-acquired IE (CA-IE) with HAIE and non-nosocomial healthcare-associated IE (NNHCA-IE). A retrospective, consecutive case-series analysis was organized and performed during the 20-year study period in Huashan Hospital, Shanghai, China. A total of 154 patients were enrolled, including 126 (81.8%) who had CA-IE and 28 (18.2%) who had HAIE, among whom 20 (71.4%) had non-nosocomial IE. Patients with HAIE compared to patients with CA-IE had poorer clinical conditions (Charlson comorbidity index ≥2: 35.7% vs. 15.1%, P = 0.012; immunosuppressive therapy: 21.4% vs. 4.0%, P = 0.005), underwent more prosthetic valve replacement (35.7% vs. 7.1%, P <0.001), had less streptococcus infection (16.7% vs. 51.1%, P = 0.007) but more atypical bacterial infection (50.0% vs. 21.1%, P = 0.017) and poorer outcomes (17.9% vs. 4.0%, P = 0.019). It is noteworthy that the results were quite similar between the comparison of patients with NNHCA-IE and those with CA-IE. Overall, in-hospital mortality was 6.5%. The IE acquisition site and low serum albumin levels (odds ratio (OR): 0.8; P = 0.04) were significantly associated with an increased risk of mortality. Nosocomial IE patients had an 8.3-fold and NNHCA-IE patients had 6.5-fold increase in the risk of mortality compared to CA-IE patients. In conclusion, HAIE and NNHCA-IE have important epidemiological and prognostic implications. Because NNHCA-IE usually occurs in patients residing in the community, it is suggested that these patients should be identified and treated by the community primary care clinical staff as early as possible.

Infective endocarditis involving an apparently structurally normal valve: new epidemiological trend?

Infective endocarditis (IE) has been increasingly diagnosed in patients without previously detected predisposing heart disease, but its clinical features have yet to be fully determined. A recent single-center study including echocardiographic images and surgical findings investigated the incidence of undiagnosed, clinically silent valvular or congenital heart diseases and healthcare-associated infective endocarditis (HAIE). The study confirmed that a large proportion of patients with IE have no previous history of heart disease. Analysis of underlying disease in these patients showed that undetected mitral valve prolapse was the most common disease, followed by an apparently structurally normal valve. The patients who developed IE of apparently structurally normal valves had different clinical characteristics and worse outcomes. IE involving a structurally normal valve was associated with both nosocomial and non-nosocomial HAIE, whereas community-acquired IE was more frequent than HAIE. The pathophysiologic mechanism involving the development of non-HAIE or community-acquired IE due to predominantly staphylococcal infection in an apparently structurally normal valve is not yet clearly understood. Structurally normal valves are not necessarily free of regurgitation or abnormal turbulence and, given the dynamic nature and fluctuating hemodynamic effects of conditions such as poorly controlled hypertension, end-stage renal disease, and sleep apnea, further investigation is necessary to evaluate the potential role of these diseases in the development of IE. An apparently normal-looking valve is associated with IE development in patients without previously recognized predisposing heart disease, warranting repartition of at-risk groups to achieve better clinical outcomes.

Infective endocarditis in the Pacific: clinical characteristics, treatment and long-term outcomes

Introduction

Data on clinical characteristics and outcomes of infective endocarditis (IE) in the Pacific are scarce.

Methods

Retrospective hospital-based study in New Caledonia, a high-income country, on patients aged over 18 years with definite IE according to the modified Duke criteria (2005–2010).

Results

51 patients were included: 31 (60.8%) men; median age of 52.4 years (IQR 33.0–70.0). Left-sided IE accounted for 47 (92.2%) patients: native valve IE in 34 (66.7%) and prosthetic valve IE in 13 (25.5%). The main underlying heart disease included: rheumatic valve disease in 19 (37.3%), degenerative heart valve disease in 12 (23.5%) and congenital heart disease in 6 (11.8%). Significant comorbidities (Charlson's score >3) were observed in 20 (38.7%) patients. Infection was community acquired in 43 (84.3%) patients. Leading pathogens included Staphylococcus aureus in 16 (31.4%) and Streptococcus spp in 15 (29.4%) patients. Complications were noted in 33 patients (64.7%) and 24 (47.1%) were admitted to the intensive care unit. Cardiac surgery was eventually performed in 22 of 40 (55.0%) patients with a theoretical indication. None underwent emergent cardiac surgery (ie, first 24 h); 2 (3.9%) were operated within 7 days; and 20 (39.2%) beyond 7 days. 11 (21.6%) patients died in hospital and 21 (42.9%) were dead after a median follow-up of 28.8 months (IQR 4.6–51.2). Two (3.9%) were lost to follow-up.

Conclusions

In New Caledonia, IE afflicts relatively young patients with rheumatic heart disease, and carries high complication and mortality rates. Access to heart surgery remains relatively limited in this remote archipelago.

Clinical epidemiology in Italian Registry of Infective Endocarditis (RIEI): Focus on age, intravascular devices and enterococci

INTRODUCTION

The epidemiology of infective endocarditis (IE) is changing due to a number of factors, including aging and health related comorbidities and medical procedures. The aim of this study is to describe the main clinical, epidemiologic and etiologic changes of IE from a large database in Italy.

METHODS

We prospectively collected episodes of IE in 17 Italian centers from July 2007 to December 2010.

RESULTS

We enrolled 677 patients with definite IE, of which 24% health-care associated. Patients were male (73%) with a median age of 62 years (IQR: 49-74) and 61% had several comorbidities. One hundred and twenty-eight (19%) patients had prosthetic left side IE, 391 (58%) native left side IE, 94 (14%) device-related IE and 54 (8%) right side IE. A predisposing cardiopathy was present in 50%, while odontoiatric and non odontoiatric procedures were reported in 5% and 21% of patients respectively. Symptoms were usually atypical and precocious. The prevalent etiology was represented by Staphylococcus aureus (27%) followed by coagulase-negative staphylococci (CNS, 21%), Streptococcus viridans (15%) and enterococci (14%). CNS and enterococci were relatively more frequent in patients with intravascular devices and prosthesis and S. viridans in left native valve. Diagnosis was made by transthoracic and transesophageal echocardiography in 62% and 94% of cases, respectively. The in-hospital mortality was 14% and 1-year mortality was 21%.

CONCLUSION

The epidemiology is changing in Italy, where IE more often affects older patients with comorbidities and intravascular devices, with an acute onset and including a high frequency of enterococci. There were few preceding odontoiatric procedures.

Epidemiology of infective endocarditis in a tertiary-center in Jerusalem: a 3-year prospective survey

BACKGROUND

Epidemiological features of infective endocarditis have changed during the last decades because of increases in the prevalence of health care exposure and of Staphylococcus aureus bloodstream infection. Consequently, the role of surgery is evolving. We aim to provide a contemporary profile of epidemiological, microbiological, and clinical features of infective endocarditis in a tertiary medical center, and identify predictors of mortality.

METHODS

A prospective observational cohort study of consecutive adult patients with definite endocarditis according to the modified Duke criteria. Data were collected from January 1, 2009 through October 31, 2011 following a predefined case report form designed by the ICE-PCS.

RESULTS

Among 70 endocarditis episodes, 25.7% involved prosthetic valves and 11.5% were device related. Forty-four percent of episodes were health-care associated. The predominant causative microorganism on native valve, prosthetic valve and device related endocarditis was Staphylococcus aureus (33.3%). Viridans group streptococci accounted for the majority of community-acquired endocarditis (36.1%). At least one complication occurred in 50% of the episodes. One third of the patients who had an indication for surgery were operated upon. Six month case fatality ratio was 40%. Sixty-five percent of patients with a contraindication to surgery died, compared with 9% and 28.5% who were treated surgically and medically, respectively. In multivariable analysis, age was a predictor of mortality.

CONCLUSION

Compared with other series, we observed more health-care associated endocarditis, and a higher mortality. Nearly half of all deaths were in patients who had a contraindication to surgery. Careful evaluation of contraindications to surgery is warranted.

Prognostic implications of diabetes in patients with left-sided endocarditis: findings from a large cohort study

Patients with diabetes mellitus (DM) have a higher incidence of infections, and those with bacteremia are more prone to develop sepsis and infective endocarditis (IE). Nevertheless, data concerning the impact of DM on the prognosis of patients with IE are limited and sometimes contradictory. We examined the impact of DM on the inhospital outcome of left-sided IE in a large cohort of patients. We studied 594 consecutive episodes of left-sided IE diagnosed at 3 tertiary care centers. They were divided into 2 groups: episodes in patients with DM (n = 114) and episodes in patients without DM (n = 480). We retrospectively analyzed the influence of DM therapy on patient outcome. Compared to patients without DM, patients with DM were older (67 ± 10 vs. 60 ± 15 yr; p < 0.001), less frequently male (53.5% vs. 67.9%; p = 0.004), and more commonly had chronic renal failure (23.9% vs. 6.9%; p < 0.001) and chronic obstructive pulmonary disease (14.6% vs. 7.8%; p = 0.019). Enterococcus (14.9% vs. 7.4%; p = 0.011) and Streptococcus bovis (8.8% vs. 3.8%; p = 0.024) were isolated more frequently. In the univariable analysis, septic shock (29.2% vs. 16.4%; p = 0.005) and mortality (43.5% vs. 30.0%; p = 0.008) were more common among patients with DM than in those without. Considering the different treatments for DM, septic shock (33.3%; p = 0.011) and death (50.8%; p = 0.012) were more frequent in patients receiving oral medication to treat diabetes than in patients with the other treatment modalities. However, multivariable analysis showed that DM had an independent association with development of septic shock (OR 2.282; 95% CI 1.186-4.393), but it was not a predictor of inhospital mortality.Staphylococci were the most frequently involved microorganisms in all patients; however, Enterococcus and Streptococcus bovis were more frequently isolated from individuals with DM and left-sided IE, whereas viridans group streptococci were more commonly isolated from those with left-sided IE who did not have DM. DM was independently associated with the development of septic shock, but it was not an independent predictor of inhospital mortality in patients with left-sided IE.