Thirty-Day Readmission After Infective Endocarditis: Analysis From a Nationwide Readmission Database

Savings associated with surgical aortic valve replacement with a RESILIA tissue valve based on seven-year COMMENCE trial results

Introduction: Bioprostheses with RESILIA tissue demonstrate a reduction in calcification and improve health outcomes in pre-clinical and clinical studies. Prior economic analyses which relied on five years of evidence from the COMMENCE trial demonstrate financial savings for RESILIA tissue valves relative to mechanical valves after surgical aortic valve replacement (SAVR). Given the recent release of 7-year COMMENCE data, this economic evaluation updates the estimate for long-run savings of bioprosthetic valves with RESILIA.Methods: Simulation models estimated disease progression across two hypothetical SAVR cohorts (tissue vs. mechanical) of 10,000 patients each in the US. The primary comparison calculated the SAVR-related expenditures associated with each valve type ($US, 2023). Health outcome probabilities were based on the COMMENCE trial though Year 7 and projected for an additional 8 years based on prior studies of tissue and mechanical SAVR. Costs for key outcomes (mortality, reoperation, bleeding, thromboembolism, endocarditis) and anticoagulant monitoring were sourced from the literature. Incidence rates of health outcomes associated with mechanical valves relied on relative risks of tissue valve versus mechanical valve patients.Results: Seven-year savings are $13,415 (95% CI: $10,472-$17,321) per patient when comparing RESILIA versus mechanical SAVR. Projected 15-year savings were $23,001 ($US, 2023; 95% CI: $17,802-$30,421). Most of the 15-year savings are primarily attributed to lower anti-coagulation monitoring costs ($21,073 in ACM savings over 15 years), but lower bleeding cost (savings: $2,294) and thromboembolism-related expenditures (savings: $852) also contribute. Reoperation and endocarditis expenditures were slightly larger in the RESILIA cohort. If reoperation relative risk reverts from 1.1 to 2.2 (the level in legacy tissue valves) after year 7, savings are $18,064. RESILIA SAVR also reduce costs relative to legacy tissue valves.Conclusion: Patients receiving RESILIA tissue valves are projected to have lower SAVR-related health expenditures relative to mechanical and legacy tissue valves.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

18F-FDG PET/CT and radiolabeled leukocyte SPECT/CT imaging for the evaluation of cardiovascular infection in the multimodality context: ASNC Imaging Indications (ASNC I2) Series Expert Consensus Recommendations from ASNC, AATS, ACC, AHA, ASE, EANM, HRS, IDSA, SCCT, SNMMI, and STS

This document on cardiovascular infection, including infective endocarditis, is the first in the American Society of Nuclear Cardiology Imaging Indications (ASNC I2) series to assess the role of radionuclide imaging in the multimodality context for the evaluation of complex systemic diseases with multi-societal involvement including pertinent disciplines. A rigorous modified Delphi approach was used to determine consensus clinical indications, diagnostic criteria, and an algorithmic approach to diagnosis of cardiovascular infection including infective endocarditis. Cardiovascular infection incidence is increasing and is associated with high morbidity and mortality. Current strategies based on clinical criteria and an initial echocardiographic imaging approach are effective but often insufficient in complicated cardiovascular infection. Radionuclide imaging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and single photon emission computed tomography/CT leukocyte scintigraphy can enhance the evaluation of suspected cardiovascular infection by increasing diagnostic accuracy, identifying extracardiac involvement, and assessing cardiac implanted device pockets, leads, and all portions of ventricular assist devices. This advanced imaging can aid in key medical and surgical considerations. Consensus diagnostic features include focal/multi-focal or diffuse heterogenous intense 18F-FDG uptake on valvular and prosthetic material, perivalvular areas, device pockets and leads, and ventricular assist device hardware persisting on non-attenuation corrected images. There are numerous clinical indications with a larger role in prosthetic valves, and cardiac devices particularly with possible infective endocarditis or in the setting of prior equivocal or non-diagnostic imaging. Illustrative cases incorporating these consensus recommendations provide additional clarification. Future research is necessary to refine application of these advanced imaging tools for surgical planning, to identify treatment response, and more.

Total-Body PET/CT Applications in Cardiovascular Diseases: A Perspective Document of the SNMMI Cardiovascular Council

Digital PET/CT systems with a long axial field of view have become available and are emerging as the current state of the art. These new camera systems provide wider anatomic coverage, leading to major increases in system sensitivity. Preliminary results have demonstrated improvements in image quality and quantification, as well as substantial advantages in tracer kinetic modeling from dynamic imaging. These systems also potentially allow for low-dose examinations and major reductions in acquisition time. Thereby, they hold great promise to improve PET-based interrogation of cardiac physiology and biology. Additionally, the whole-body coverage enables simultaneous assessment of multiple organs and the large vascular structures of the body, opening new opportunities for imaging systemic mechanisms, disorders, or treatments and their interactions with the cardiovascular system as a whole. The aim of this perspective document is to debate the potential applications, challenges, opportunities, and remaining challenges of applying PET/CT with a long axial field of view to the field of cardiovascular disease.

Outcomes after bioprosthetic versus mechanical mitral valve replacement for infective endocarditis in the United States

Objective

In patients who underwent mitral valve replacement for infectious endocarditis, we evaluated the association of prosthesis choice with readmission rates and causes (the primary outcomes), as well as with in-hospital mortality, cost, and length of stay (the secondary outcomes).

Methods

Patients with infectious endocarditis who underwent isolated mitral valve replacement from January 2016 to December 2018 were identified in the United States Nationwide Readmissions Database and stratified by valve type. Propensity score matching was used to compare adjusted outcomes.

Results

A weighted total of 4206 patients with infectious endocarditis underwent bioprosthetic mitral valve replacement (n = 3132) and mechanical mitral valve replacement (n = 1074) during the study period. Patients in the bioprosthetic mitral valve replacement group were older than those in the mechanical mitral valve replacement group (median 57 vs 46 y, P < .001). After propensity matching, the bioprosthetic mitral valve replacement group (n = 1068) had similar in-hospital mortality, length of stay, and costs compared with the mechanical mitral valve replacement group (n = 1056). Overall, 90-day readmission rates were high (28.9%) and comparable for bioprosthetic mitral valve replacement (30.5%) and mechanical mitral valve replacement (27.5%, P = .4). Likewise, there was no difference in readmissions over a calendar year by prosthesis type. Readmissions for infection and bleeding were common for both bioprosthetic mitral valve replacement and mechanical mitral valve replacement groups.

Conclusions

Outcomes and readmission rates were similar for mechanical mitral valve replacement and bioprosthetic mitral valve replacement in infectious endocarditis, suggesting that valve choice should not be determined by endocarditis status. Additionally, strategies to mitigate readmission for infection and bleeding are needed for both groups.

Prevalence, Characteristics, and Outcomes of Infective Endocarditis Readmissions in Patients With Variables Associated With Liver Disease in the United States

Infective endocarditis (IE) is common in patients with liver disease. Outcomes of IE in patients with liver disease are limited. We aimed to investigate IE outcomes in patients with variables associated with liver disease in the USA. We used the 2017 National Readmission Database to identify index admission of adults with IE, based on the International Classification of Disease, 10th revision codes. The primary outcome was 30-day readmission. Secondary outcomes were mortality and predictors of hospital readmission. We identified 40,413 IE admissions. Patients who were readmitted were more likely to have a history of HCV (19.4 vs 12.3%, P < .001), hyponatremia (25 vs 21%, P < .001), and thrombocytopenia (20.3 vs 16.3%, P < .001). After adjusting for age, hypertension, heart failure, diabetes mellitus, and end stage renal disease, hyponatremia (odds ratio (OR) 1.25; 95% confidence intervals [CI]: 1.17-1.35; P < .001) and thrombocytopenia (OR 1.16; 95% CI: 1.08-1.24; P < .001) correlated with higher odds of 30-day readmission. Mortality was higher among patients with hyponatremia (29 vs 22%, P < .001), thrombocytopenia (29 vs 17%, P < .001), coagulopathy (12 vs 5%, P < .001), cirrhosis (6 vs 4%, P < .001), ascites (7 vs 3%, P < .001), liver failure (18 vs 3%, P < .001), and portal hypertension (3 vs 1.5%, P < .001).

Trends in Infective Endocarditis Mortality in the United States: 1999 to 2020: A Cause for Alarm

BACKGROUND

Data on national trends in mortality due to infective endocarditis (IE) in the United States are limited.

METHODS AND RESULTS

Utilizing the multiple causes of death data from the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2020, IE and substance use were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification codes. Between 1999 and 2020, the IE-related age-adjusted mortality rates declined. IE-related crude mortality accelerated significantly in the age groups 25-34 years (average annual percentage change, 5.4 [95% CI, 3.1-7.7]; P<0.001) and 35-44 years (average annual percentage change, 2.3 [95% CI, 1.3-3.3]; P<0.001), but remained stagnant in those aged 45-54 years (average annual percentage change, 0.5 [95% CI, -1.9 to 3]; P=0.684), and showed a significant decline in those aged ≥55 years. A concomitant substance use disorder as multiple causes of death in those with IE increased drastically in the 25-44 years age group (P<0.001). The states of Kentucky, Tennessee, and West Virginia showed an acceleration in age-adjusted mortality rates in contrast to other states, where there was predominantly a decline or static trend for IE.

CONCLUSIONS

Age-adjusted mortality rates due to IE in the overall population have declined. The marked acceleration in mortality in the 25- to 44-year age group is a cause for alarm. Regional differences with acceleration in IE mortality rates were noted in Kentucky, Tennessee, and West Virginia. We speculate that this acceleration was likely due mainly to the opioid crisis that has engulfed several states and involved principally younger adults.

Human Serum Supplementation Promotes Streptococcus mitis Growth and Induces Specific Transcriptomic Responses

Streptococcus mitis is a normal member of the human oral microbiota and a leading opportunistic pathogen causing infective endocarditis (IE). Despite the complex interactions between S. mitis and the human host, understanding of S. mitis physiology and its mechanisms of adaptation to host-associated environments is inadequate, especially compared with other IE bacterial pathogens. This study reports the growth-promoting effects of human serum on S. mitis and other pathogenic streptococci, including S. oralis, S. pneumoniae, and S. agalactiae. Using transcriptomic analyses, we identified that, with the addition of human serum, S. mitis downregulates uptake systems for metal ions and sugars, fatty acid biosynthetic genes, and genes involved in stress response and other processes related with growth and replication. S. mitis upregulates uptake systems for amino acids and short peptides in response to human serum. Zinc availability and environmental signals sensed by the induced short peptide binding proteins were not sufficient to confer the growth-promoting effects. More investigation is required to establish the mechanism for growth promotion. Overall, our study contributes to the fundamental understanding of S. mitis physiology under host-associated conditions. IMPORTANCE S. mitis is exposed to human serum components during commensalism in the human mouth and bloodstream pathogenesis. However, the physiological effects of serum components on this bacterium remain unclear. Using transcriptomic analyses, S. mitis biological processes that respond to the presence of human serum were revealed, improving the fundamental understanding of S. mitis physiology in human host conditions.

Long-run savings associated with surgical aortic valve replacement using a RESILIA tissue bioprosthetic valve versus a mechanical valve

BACKGROUND

Prior economic analyses demonstrate that legacy tissue valves are associated with substantial financial savings over the long run after a surgical aortic valve replacement (SAVR). Bioprostheses with RESILIA tissue reduce calcification, the primary cause of structural valve deterioration (SVD), and have demonstrated promising pre-clinical and 5-year clinical results. This economic evaluation quantifies the expected long-run savings of bioprosthetic valves with RESILIA tissue relative to mechanical valves given 5-year clinical results and expected performance through year 15.

METHODS

Simulation models estimated disease progression across two hypothetical SAVR cohorts (tissue vs. mechanical) of 10,000 patients in the US over 15 years. One comparison evaluated RESILIA tissue valves relative to mechanical valves. The other compared legacy SAVR tissue and mechanical valves. Health outcome probabilities and costs were based on literature and expert opinion. Incidence rates of health outcomes associated with mechanical valve were calculated using relative risks of expected outcomes in tissue valve versus mechanical valve patients. The comparisons also accounted for anti-coagulation monitoring in both cohorts. Savings estimates are based on US healthcare costs and do not yet account for the premium associated use of RESILIA relative to a standard tissue valve.

RESULTS

Relative to mechanical SAVR, the median net discounted savings for a patient receiving SAVR with a RESILIA tissue valve is $20,744 ($US, 2020; 95% CI = $15,835-$26,655) over a 15-year horizon. While 30-day and 1-year savings were not significant, expected savings after 5 years are $9,110 (95% CI = $6,634-$11,969). Net savings for RESILIA SAVR valves were approximately 30-50% larger than savings anticipated using legacy tissue SAVR valves.

CONCLUSION

RESILIA tissue valves are associated with lower health expenditures relative to mechanical valves.

Differences in Sex and the Incidence and In-Hospital Mortality among People Admitted for Infective Endocarditis in Spain, 2016-2020

(1) Background: A description of the trends and outcomes during hospitalization for infective endocarditis (IE) according to sex. (2) Methods: Using Spanish national hospital discharge data (2016−2020), we built Poisson regression models to compare the age-adjusted time trends for the incidence rate. We used propensity score matching (PSM) to compare the clinical characteristics and the in-hospital mortality (IHM) between men and women hospitalized with IE. (3) Results: We identified 10,459 hospitalizations for IE (33.26% women). The incidence of IE remained stable during this five-year period. The age-adjusted incidence of IE was two-fold higher among men vs. women (IRR = 2.08; 95%CI 2.0−2.17). Before PSM, women with IE were significantly older than men (70.25 vs. 66.24 years; p < 0.001) and had lower comorbidity according to the Charlson comorbidity index (mean 1.38 vs. 1.43; p = 0.019). After PSM, the IHM among women admitted for IE remained >3 points higher than that among men (19.52% vs. 15.98%; p < 0.001). (4) Conclusions: The incidence of IE was two-fold higher among men than among women. IHM was significantly higher among women after accounting for the potential confounders.

Impact of Opioid Epidemic on Infective Endocarditis Outcomes in the United States: From the National Readmission Database

Infective endocarditis (IE) is associated with marked morbidity and mortality in the United States and parallels the opioid pandemic. Few studies explore this interaction and its effect on clinical outcomes. We analyzed contemporary patients admitted with IE to determine predictors of readmission in the United States. The 2017 National Readmission Database was used to identify index admissions in adults with the diagnosis of IE, based on the International Classification of Disease, 10th Revision codes. The primary outcome of interest was 30-day readmission. Secondary outcomes were mortality, hospital charges, and predictors of hospitalization readmission. Of 40,413 index admissions for IE, 5,558 patients (13.8%) were readmitted within 30 days. Patients who were readmitted were younger (55 ± 20 vs 61 ± 19 years, p <0.001) and more likely to have end-stage renal disease (12.2% vs 10.5%, p <0.001), hepatitis C virus (19.4% vs 12.6%, p <0.001), HIV (1.8% vs 1.2%, p = 0.001), opioid abuse (23.9% vs 15%, p <0.001), cocaine use (7.3% vs 4.4%, p <0.001), and other substance abuse (8.5 vs 5.6, p <0.001). Patients readmitted were less likely to have diabetes mellitus (27.8% vs 29.4%, p = 0.01), hypertension (56.9% vs 64%, p <0.001), heart failure (37.7% vs 40%, p <0.001), chronic kidney disease (31.2% vs 32%, p <0.001), and peripheral vascular disease (3.6% vs 4.6%, p = 0.001). The median cost of index admission for the total cohort was $84,325 (39,922 to 190,492). After adjusting for age, diabetes mellitus, heart failure, hypertension, and end-stage renal disease, opioid abuse (odds ratio [OR] 1.34; 95% confidence interval [CI] 1.23 to 1.46; p <0.001), cocaine use (OR 1.32; 95% CI 1.17 to 1.48; p <0.001), other substance abuse (OR 1.16; 95% CI 1.04 to 1.30; p = 0.008), and hepatitis C virus (OR 1.32; 95% CI 1.21 to 1.43; p <0.001) correlated with higher odds of 30-day readmission. These factors may present targets for future intervention.

Effect of leaving against medical advice on 30-day infective endocarditis readmissions

BACKGROUND

: The burden of against medical advice (AMA) discharges on the readmission rate of infective endocarditis (IE) patients has been largely ignored.

METHODS

We used the National Readmissions Database, years 2016 to 2019, to identify IE patients and categorized them into those who left AMA (IE AMA) and those who were discharged to home or skilled nursing facility (SNF)/other facility (IE non-AMA). The primary outcome was 30-day all-cause readmissions difference per AMA status.

RESULTS

Of 26,481 patients with IE who met the inclusion criteria, 4,310 (16.3%) left the hospital AMA. IE AMA patients were younger (mean years; 43.7 vs 34.2; p < 0.01) and had a higher prevalence of injection drug use (IDU) (89.4% vs 45.2%; p < 0.01) but fewer comorbidities compared to IE non-AMA. In adjusted analyses, IE AMA had higher hazards for 30-day readmissions compared to IE non-AMA [hazards ratio (HR): 3.1 (2.9 - 3.5); p < 0.01].

CONCLUSION

IE AMA are at increased risk of 30-day readmissions and higher resource utilization at the time of readmission compared to IE non-AMA. Considering the high prevalence of IDU in IE AMA, the role of mental health to curb the burden of IE readmissions is an area of further research.

Severe bacterial infections in people who inject drugs: the role of injection-related tissue damage

Background

In the context of the current U.S. injection drug use epidemic, targeted public health harm reduction strategies have traditionally focused on overdose prevention and reducing transmission of blood-borne viral infections. Severe bacterial infections (SBI) associated with intravenous drug use have been increasing in frequency in the U.S. over the last decade. This qualitative study aims to identify the risk factors associated with SBI in hospitalized individuals with recent injection drug use.

Methods

Qualitative analysis (n = 15) was performed using an in-depth, semi-structured interview of participants admitted to Bellevue Hospital, NYC, with SBI and recent history of injection drug use. Participants were identified through a referral from either the Infectious Diseases or Addition Medicine consultative services. Interviews were transcribed, descriptively coded, and analyzed for key themes.

Results

Participants reported a basic understanding of prevention of blood-borne viral transmission but limited understanding of SBI risk. Participants described engagement in high risk injection behaviors prior to hospitalization with SBI. These practices included polysubstance use, repetitive tissue damage, nonsterile drug diluting water and multipurpose use of water container, lack of hand and skin hygiene, re-use of injection equipment, network sharing, and structural factors leading to an unstable drug injection environment. Qualitative analysis led to the proposal of an Ecosocial understanding of SBI risk, detailing the multi-level interplay between individuals and their social and physical environments in producing risk for negative health outcomes.

Conclusions

Structural factors and injection drug use networks directly impact drug use, injection drug use practices, and harm reduction knowledge, ultimately resulting in tissue damage and inoculation of bacteria into the host and subsequent development of SBI. Effective healthcare and community prevention efforts targeted toward reducing risk of bacterial infections could prevent long-term hospitalizations, decrease health care expenditures, and reduce morbidity and mortality.

Epidemiology of infective endocarditis: novel aspects in the twenty-first century

INTRODUCTION

The epidemiology of infective endocarditis (IE) in this millennium has changed with emergence of new risk factors and reemergence of others. This, coupled with modifications in national guidelines in the setting of a pandemic, prompted an address of the topic.

AREAS COVERED

Our goal is to provide a contemporary review of IE epidemiology considering changing incidence of rheumatic heart disease (RHD), cardiac device implantation, and injection drug use (IDU), with SARS-CoV-2 pandemic as the backdrop.

METHODS

PubMed and Google Scholar were used to identify studies of interest.

EXPERT OPINION

Our experience over the past two decades verifies the notion that there is not one 'textbook' profile of IE. Multiple factors have dramatically impacted IE epidemiology, and these factors differ, based, in part on geography. RHD has declined in many areas of the world, whereas implanted cardiovascular devices-related IE has grown exponentially. Perhaps the most influential, at least in areas of the United States, is injection drug use complicating the opioid epidemic. Healthy younger individuals contracting a potentially life-threatening infection has been tragic. In the past year, epidemiological changes due to the COVID-19 pandemic have also occurred. No doubt, changes will characterize IE in the future and serial review of the topic is warranted.

Infective endocarditis and solid organ transplantation: Only worse outcomes during initial transplantation hospitalization

BACKGROUND

The epidemiology, and outcome of infective endocarditis (IE) among solid organ transplant (SOT) recipients is unknown.

METHODS

We used data from the 2013-2018 Nationwide Readmissions Database (NRD). IE- and SOT-associated hospitalizations were identified using diagnosis and procedure codes. Outcomes included inpatient mortality, length of stay, and inpatient costs. Adjusted analyses were performed using weighted regression models.

RESULTS

A total of 99,052 IE-associated hospitalizations, corresponding to a weighted national estimate of 193,164, were included for analysis. Of these, 794 (weighted n = 1,574) were associated with transplant history (SOT-IE). Mortality was not significantly different between SOT-IE and non-SOT-IE (17.2% vs. 15.8%, adjusted relative risk [aRR]: 0.86, 95% confidence interval [CI] [0.71, 1.03]), and fewer SOT-IE patients underwent valve repair or replacement than non-SOT-IE (12.5% vs. 16.2%, aRR 0.82, 95% CI [0.71, 0.95]). We then compared outcomes of patients diagnosed with IE during their index transplant hospitalization (index-SOT-IE) to patients without IE during their transplant hospitalization (index-SOT). Index-SOT-IE occurred most frequently among heart transplant recipients (45.1%), and was associated with greater mortality (27.1% vs. 2.3%, aRR 6.07, 95% CI [3.32, 11.11]).

CONCLUSION

Dual diagnosis of SOT and IE was associated with worse outcomes among SOT recipients during index hospitalization, but not overall among patients with IE.

Pulmonary complications observed in patients with infective endocarditis with and without injection drug use: An analysis of the National Inpatient Sample

Background

The impact of cardiovascular and neurologic complications on infective endocarditis (IE) are well studied, yet the prevalence and significance of pulmonary complications in IE is not defined. To better characterize the multifaceted nature of IE management, we aimed to describe the occurrence and significance of pulmonary complications in IE, including among persons with IE related to drug use.

Methods

Hospitalizations of adult (≥18 years old) patients diagnosed with IE were identified in the 2016 National Inpatient Sample using ICD-10 codes. Multivariable logistic and linear regression were used to compare IE patient outcomes between those with and without pulmonary complications and to identify predictors of pulmonary complications. Interaction terms were used to assess the impact of drug-use IE (DU-IE) and pulmonary complications on inpatient outcomes.

Results

In 2016, there were an estimated 88,995 hospitalizations of patients diagnosed with IE. Of these hospitalizations,15,490 (17%) were drug-use related. Drug-use IE (DU-IE) had the highest odds of pulmonary complications (OR 2.97, 95% CI 2.50, 3.45). At least one pulmonary complication was identified in 6,580 (7%) of IE patients. DU-IE hospitalizations were more likely to have a diagnosis of pyothorax (3% vs. 1%, p<0.001), lung abscess (3% vs. <1%, p<0.001), and septic pulmonary embolism (27% vs. 2%, p<0.001). Pulmonary complications were associated with longer average lengths of stay (CIE 7.22 days 95% CI 6.11, 8.32), higher hospital charges (CIE 78.51 thousand dollars 95% CI 57.44, 99.57), more frequent post-discharge transfers (acute care: OR 1.37, 95% CI 1.09, 1.71; long-term care: OR 2.19, 95% CI 1.83, 2.61), and increased odds of inpatient mortality (OR 1.81 95% CI 1.39, 2.35).

Conclusion and relevance

IE with pulmonary complications is associated with worse outcomes. Patients with DU-IE have a particularly high prevalence of pulmonary complications that may require timely thoracic surgical intervention, likely owing to right-sided valve involvement. More research is needed to determine optimal management strategies for complications to improve patient outcomes.

Short- and long-term outcomes of infective endocarditis admission in adults: A population-based registry study in Finland

Infective endocarditis (IE) is associated with high mortality. However, data on factors associated with length of stay (LOS) in hospital due to IE are scarce. In addition, long-term mortality of more than 1 year is inadequately known. In this large population-based study we investigated age and sex differences, temporal trends, and factors affecting the LOS in patients with IE and in-hospital, 1-year, 5-year and 10-year mortality of IE. Data on patients (≥18 years of age) admitted to hospital due to IE in Finland during 2005–2014 were collected retrospectively from nationwide obligatory registries. We included 2166 patients in our study. Of the patients 67.8% were men. Women were older than men (mean age 63.3 vs. 59.5, p<0.001). The median LOS was 20.0 days in men and 18.0 in women, p = 0.015. In the youngest patients (18–39 years) the median LOS was significantly longer than in the oldest patients (≥80 years) (24.0 vs. 16.0 days, p = 0.014). In-hospital mortality was 10% with no difference between men and women. Mortality was 22.7% at 1 year whereas 5- and 10-year mortality was 37.5% and 48.5%, respectively. The 5-year and 10-year mortality was higher in women (HR 1.18, p = 0.034; HR 1.18, p = 0.021). Both in-hospital and long-term mortality increased significantly with aging and comorbidity burden. Both mortality and LOS remained stable over the study period. In conclusion, men had longer hospital stays due to IE compared to women. The 5- and 10-year mortality was higher in women. The mortality of IE or LOS did not change over time.

Comprehensive cardiac rehabilitation for patients following infective endocarditis: results of the randomized CopenHeartIE trial

AIMS

Infective endocarditis is a complex and highly mortal disease requiring lengthy treatment. Physical and mental deconditioning is common. Nonetheless, rehabilitation is virtually unexplored in this population. The aim of this trial was therefore to investigate the effects of cardiac rehabilitation in patients following endocarditis.

METHODS AND RESULTS

In a randomized trial, adults with left-sided or cardiac device endocarditis were randomized 1:1 to 12 weeks of physical exercise training and five psycho-educational consultations (cardiac rehabilitation) vs. usual care without rehabilitation (control). Primary outcome was mental health measured by SF-36 Mental Component Summary (MCS) at 6 months. Secondary outcome was physical capacity measured by peak oxygen uptake (VO2) at 4 months. Exploratory outcomes were investigated. Low inclusion rate resulted in trial termination before reaching the target sample size. A total of 117 participants (mean age: 60 years, 81% male) were randomized to cardiac rehabilitation (n = 58) or to control (n = 59). Mental health and physical capacity at baseline were generally poor (MCS: 38.9-42.2 points, VO2 peak: 16.1-16.6 mL/kg/min). Cardiac rehabilitation compared with control showed no effect on mental health (MCS: 44.6 points vs. 48.8 points, P = 0.41) or physical capacity (VO2 peak: 19.9 mL/kg/min vs. 18.0 mL/kg/min, P = 0.09). Effects favouring the intervention were identified in exploratory outcomes including general fatigue (P = 0.005), and physical capacity as maximal power (W) (P = 0.005). Adherence to the intervention was 28%.

CONCLUSIONS

Results indicate no effect of cardiac rehabilitation in patients following endocarditis; however, lack of statistical power and poor adherence render findings inconclusive. Valuable insight into patients' capabilities and safety was gained, and further investigations into rehabilitation needs and modes of delivery in this high-need population should be a future priority.

A Contemporary Population-Based Profile of Infective Endocarditis Using the Expanded Rochester Epidemiology Project

OBJECTIVE

To develop a contemporary profile of infective endocarditis (IE) among a population in 6 counties of Olmsted, Dodge, Mower, Steele, Waseca, and Freeborn in southern Minnesota between 2014 and 2018.

PATIENTS AND METHODS

All possible and definite cases of IE (≥18 years) among residents of 6 counties in southern Minnesota, including Olmsted County, diagnosed between January 1, 2014, and December 31, 2018, were included in this retrospective, population-based investigation, using the Expanded Rochester Epidemiology Project (E-REP).

RESULTS

Overall, 137 patients with IE developed incident IE in the 6-county region, corresponding to an age- and sex-adjusted incidence rate of 11.9 per 100,000 person-years. Men had a significantly higher incidence of IE (17.9 vs 6.8 per 100,000 person-years), and rates increased exponentially with age in both sexes. The median age of incident cases was 68.2 years, and 67.9% were male patients. The percentage of patients with histories of injection-drug use was low, at 6.7%. Bicuspid aortic valve was the most common (9.6%) native valve predisposing condition. Staphylococcus aureus was identified as the predominant pathogen in the overall group (34.8%), with viridans-group streptococci accounting for only 19.3% cases. Central nervous system and musculoskeletal complications were common. The 30-day readmission rate was 27.9%, and the 6-month mortality rate was 31.8%.

CONCLUSION

To our knowledge, this is the first time that the population-based E-REP has been used to determine an age- and sex-adjusted IE incidence. Older male patients predominated, and S aureus was the most common pathogen. Based on these findings, it is not surprising that IE complications were frequently seen.

Insight into the epidemiology of infective endocarditis in Portugal: a contemporary nationwide study from 2010 to 2018

BACKGROUND

Nationwide hospital admissions data series have contributed to a reliable assessment of the changing epidemiology of infective endocarditis, even though conclusions are not uniform. We sought to use a recent populational series to describe the temporal trends on the incidence of infective endocarditis, its clinical characteristics and outcome results, in Portugal.

METHODS

A nationwide retrospective temporal trend study on the incidence and clinical characterization of patients hospitalized with infective endocarditis, between 2010 and 2018.

RESULTS

7574 patients were hospitalized with infective endocarditis from 2010 to 2018 in Portuguese public hospitals. The average length of hospitalization was 29.3 ± 28.7 days, predominantly men (56.9%), and 47.1% had between 60 and 79 years old. The most frequent infectious agents involved were Staphylococcus (16.4%) and Streptococcus (13.6%). During hospitalization, 12.4% of patients underwent heart valve surgery and 20% of the total cohort died. After a 1-year post-discharge follow-up, 13.2% of the total initial cohort had had heart valve surgery and 21.2% in total died. The annual incidence of infective endocarditis was 8.31 per 100,000 habitants, being higher in men (9.96 per 100,000 in males versus 6.82 in females, p < 0.001) and increased with age, peaking at patients 80 years old or older (40.62 per 100,000). In-hospital mortality rate significantly increased during the analyzed period, the strongest independent predictors being ischemic or hemorrhagic stroke, sepsis, and acute renal failure. Younger age and cardiac surgery had a protective effect towards a fatal outcome.

CONCLUSIONS

In Portugal, between 2010 and 2018, the incidence of infective endocarditis presented a general growth trend with a deceleration in the most recent years. Also, a significant rate of in-hospital complications, a mildly lower than expected stable surgical rate and a still high and growing mortality rate were noted.

Thirty-Day Readmission After Infective Endocarditis: Analysis From a Nationwide Readmission Database

Background

The contemporary incidence of and reasons for early readmission after infective endocarditis (IE) are not well known. Therefore, we analyzed 30‐day readmission demographics after IE from the US Nationwide Readmission Database.

Methods and Results

We examined the 2010 to 2014 Nationwide Readmission Database to identify index admissions for a primary diagnosis of IE with survival at discharge. Incidence, reasons, and independent predictors of 30‐day unplanned readmissions were analyzed. In total, 11 217 patients (24.8%) were nonelectively readmitted within 30 days among the 45 214 index admissions discharged after IE. The most common causes of readmission were IE (20.5%), sepsis (8.7%), complications of device/graft (8.1%), and congestive heart failure (7.6%). In‐hospital mortality and the valvular surgery rates during the readmissions were 8.1% and 9.1%, respectively. Discharge to home or self‐care, undergoing valvular surgery, aged ≥60 years, and having private insurance were independently associated with lower rates of 30‐day readmission. Length of stay of ≥10 days, congestive heart failure, diabetes mellitus, renal failure, chronic pulmonary disease, peripheral artery disease, and depression were associated with higher risk. The total hospital costs of readmission were $48.7 million per year (median, $11 267; interquartile range, $6021–$25 073), which accounted for 38.6% of the total episodes of care (index+readmission).

Conclusions

Almost 1 in 4 patients was readmitted within 30 days of admission for IE. The most common reasons were IE, other infectious causes, and cardiac causes. A multidisciplinary approach to determine the surgical indications and close monitoring are necessary to improve outcomes and reduce complications in in‐hospital and postdischarge settings.

Impact of Malnutrition in Patients With Infective Endocarditis

BACKGROUND

Effects of malnutrition on patients with infective endocarditis (IE) have not been fully studied. Because malnutrition is associated with poor health, we hypothesized that among patients with IE, those with malnutrition would have more negative in-hospital outcomes.

METHODS

The National Inpatient Sample was used to identify adults ≥18 years old with IE. We compared outcomes of in-hospital mortality, morbidity, valvular interventions, and utilization of resources between individuals with and without malnutrition.

RESULTS

11,939 adults ≥18 years were hospitalized with IE, 2035 had a secondary diagnosis for malnutrition. There were no significant differences in age (mean age ± SEM: 55.6 ± 1.0 vs 54.3 ± 0.4 years, P = .21) or sex (female: 36.7%; 743/2,035 vs 37.5%; 3,717/9,904, P = .69) in patients with and without malnutrition. Patients with malnutrition had more comorbidities (Charlson comorbidity score ≥3: 36%; 732/2,035 vs 30.7%; 3,040/9,904, P = .04). Despite similar adjusted in-hospital mortality (adjusted odds ratio [aOR], 1.4; 95% CI, 0.8-1.5; P = .23), malnourished patients were more likely to develop sepsis (aOR, 1.7; 95% CI, 1.2-2.4; P < .01) and had higher odds of mitral-valve (aOR, 1.7; 95% CI, 1.2-2.4; P < .01) repairs/replacements. Patients with malnutrition also had increased lengths of stay (adjusted mean difference [aMD], 4.7 days; 95% CI, 2.9-6.5 days; P < .01) and hospital charges (aMD, $36,052; 95% CI, $14,935-$57,168; P < .01).

CONCLUSIONS

Patients with malnutrition and IE are at risk for high morbidity, valvular repairs/replacements, and use of hospital resources.

Infective Endocarditis as a Complication of Intravenous Drug Use in Pregnancy: A Retrospective Case Series and Literature Review

Objective  An increase in opioid use disorder and subsequent intravenous drug use has led to an increase in sequalae that may complicate pregnancy, such as infective endocarditis. Infective endocarditis has the potential for significant maternal and neonatal morbidity and mortality. We sought to examine the management considerations and clinical implications of intravenous drug use-related infective endocarditis in pregnancy from our center's experience. Study Design  Retrospective study of management of pregnancies complicated by infective endocarditis as a result of active intravenous drug use at an academic tertiary care hospital from January 2012 through December 2019. Results  Twelve women with active intravenous drug use histories were identified as having clinical and echocardiographic features consistent with infective endocarditis. Six women were discharged against medical advice and did not complete the full course of recommended antibiotic regimen. Eight women were started or continued on opioid agonist therapy during their hospitalization. Four neonates required neonatal intensive care unit admission for pharmacologic treatment for neonatal abstinence syndrome. Conclusion  Management of intravenous drug use-associated infective endocarditis in pregnancy involves more than treating the acute condition. In pregnant women with opioid use disorder and infective endocarditis, addiction and chronic psychosocial conditions need to be addressed to optimize care.

Infective Endocarditis: Preliminary Results of a Cohort Study in the Southern Italian Population

Background

Infective endocarditis (IE) is an uncommon disease with an involved interplay of clinical and surgical team management. We aimed to define diagnosis parameters and delineate in-hospital management in patients with IE admitted in a tertiary hospital of Southern Italian.

Materials and methods

Fifty-six consecutive patients (42 males, 14 females; age range: 34-85 years) admitted for IE in the Infectious Diseases, Cardiac Surgery, and Cardiology units, between January 2011 and August 2017, were enrolled. Demographic data, mortality, comorbidities, specimen type, microscopy results, special histological staining performed, and antimicrobial therapy were collected and analyzed. Any comments at the multidisciplinary team meetings were recorded in minutes of and approved.

Results

We found 83.9% of patients with positive blood cultures. The four most common bacteria were methicillin-resistant Staphylococcus aureus (MRSA: 21.3%), methicillin-sensitive Staphylococcus aureus (MSSA: 17%), Streptococci (14.9%), and Enterococci (14.9%). Both in the univariate and multivariate analysis, we observed a significant positive correlation between surgery and complications. Particularly in the univariate analysis only, surgery was positively correlated to males and C-reactive protein (CPR) at baseline. Also, considering the most common bacteria, it resulted in a positive correlation between surgery and MRSA and Streptococci spp. and between complications and MSSA. Finally, the male gender was positively correlated to MSSA and heart complications, major arterial embolism, septic pulmonary emboli, splenic infarction, and cerebral embolism.

Conclusions

A blood culture test remains a critical factor for the diagnosis of IE and the antibiotic treatment of susceptible and emerging resistant bacteria. Male gender and heart complications are red flags for prompt operative management.

Partial oral antibiotic therapy is non-inferior to intravenous therapy in non-critically ill patients with infective endocarditis : Review and meta-analysis

Background

Antimicrobial therapy is a cornerstone in the treatment of infective endocarditis (IE). Typically, intravenous (i.v.) therapy is given for 6 weeks or longer, leading to prolonged hospital stays and high costs. Several trials evaluating the efficacy of partial oral therapy (POT) have been published. This article aimed to review and meta-analyze studies comparing i.v. therapy versus POT in non-critically ill patients suffering from IE.

Methods

A structured database search (based on PRISMA guidelines) regarding POT versus i.v. therapy in IE was conducted using PubMed/Medline. Primary endpoint was all-cause mortality and a secondary endpoint IE relapse. Risk rates were calculated using a random effects model (DerSimonian and Laird). Heterogeneity was assessed using the I² statistics.

Results

After screening 1848 studies at title and abstract levels, 4 studies were included. A total of 765 patients suffered from primary left-sided IE, whereas right-sided IE was observed in 72 patients. Mortality rates were lower in POT versus i.v. therapy (risk ratio [RR] 0.38, 95% confidence interval, confidence interval [CI] 0.20–0.74; p = 0.004; I² 0%). IE relapse rates were similar (RR 0.63, 95% CI 0.29–1.37; p = 0.24; I² 0%).

Conclusion

Data comparing POT with standard care in IE is limited and to date only one sufficiently powered stand-alone trial exists to support its use. In this meta-analysis POT was non-inferior to i.v. therapy with respect to mortality and IE relapse in non-critically ill patients suffering from both left-sided and right-sided IE. These findings indicate that POT is a feasible treatment strategy in selected patients suffering from IE but further validation in future studies will be required.

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.