Infective endocarditis requiring ICU admission: epidemiology and prognosis

Critically ill patients with infective endocarditis, neurological complications and indication for cardiac surgery: a multicenter propensity-adjusted study

BACKGROUND

The benefit-risk balance and optimal timing of surgery for severe infective endocarditis (IE) with ischemic or hemorrhagic strokes is unknown. The study aim was to compare the neurological outcome between patients receiving surgery or not.

METHODS

In a prospective register-based multicenter ICU study, patients were included if they met the following criteria: (i) left-sided IE with an indication for heart surgery; (ii) with cerebral complications documented by cerebral imaging before cardiac surgery; (iii) with Sequential Organ Failure Assessment score ≥ 3. Exclusion criteria were isolated right-sided IE, in-hospital acquired IE and patients with cerebral complications only after cardiac surgery. In the primary analysis, the prognostic value of surgery in term of disability at 6 month was assessed by using a propensity score-adjusted logistic regression.

RESULTS

192 patients were included including ischemic stroke (74.5%) and hemorrhagic lesion (15.6%): 67 (35%) had medical treatment and 125 (65%) cardiac surgery. In the propensity score-adjusted logistic regression, a favorable 6-month neurological outcome was associated with surgery (odds ratio 13.8 (95% CI 6.2-33.7). The 1-year mortality was strongly reduced with surgery in the fixed-effect propensity-adjusted Cox model (hazard ratio 0.18; 95% CI 0.11-0.27; p < 0.001). These effects remained whether the patients received delayed surgery (n = 62/125) or not and whether they were deeply comatose (Glasgow Coma Scale ≤ 10) or not.

CONCLUSIONS

In critically ill IE patients with an indication for surgery and previous cerebral events, a better propensity-adjusted neurological outcome was associated with surgery compared with medical treatment.

Clinical Features and Mortality Rate of Infective Endocarditis in Intensive Care Unit: A Large-Scale Study and Literature Review

BACKGROUND

Large-scale multicentric studies reported that, despite advances in diagnosis, antibiotics, and surgical treatment, infective endocarditis (IE) in-hospital mortality remains high. Most data have been obtained from patients treated in infective disease wards, internal medicine, cardiology, or cardiac surgery departments and are therefore heterogeneous. The few studies focused on complicated IE patients leading to intensive care unit (ICU) admission have reported different methodologies and results. The aim of our study was to describe the epidemiological, clinical, and microbial features of critically ill patients admitted to the ICU with a definite IE diagnosis.

METHODS

We conducted a prospective case-series population study from January 1, 1998, to December 31, 2020. Patients were divided into 2 groups: 'Ward' (group 1) and 'ICU' patients (group 2), and a 1-year follow-up was performed.

RESULTS

After performing a univariate and multivariate logistic regression analysis, we found that the independent predictors of ICU admission were vegetation diameter >10 mm, abnormal PaO2/FiO2 ratio, and acute heart failure. Five independent mortality risk factors were identified: SOFA score >14, not performing surgery, age >70 years, acute heart failure, and embolic complications.

CONCLUSIONS

Infective endocarditis in-hospital mortality remains high. ICU admission and mortality can be predicted by independent risk factors.

A New Clinical Prediction Rule for Infective Endocarditis in Emergency Department Patients With Fever: Definition and First Validation of the CREED Score

Background Infective endocarditis (IE) could be suspected in any febrile patients admitted to the emergency department (ED). This study was aimed at assessing clinical criteria predictive of IE and identifying and prospectively validating a sensible and easy-to-use clinical prediction score for the diagnosis of IE in the ED. Methods and Results We conducted a retrospective observational study, enrolling consecutive patients with fever admitted to the ED between January 2015 and December 2019 and subsequently hospitalized. Several clinical and anamnestic standardized variables were collected and evaluated for the association with IE diagnosis. We derived a multivariate prediction model by logistic regression analysis. The identified predictors were assigned a score point value to obtain the Clinical Rule for Infective Endocarditis in the Emergency Department (CREED) score. To validate the CREED score we conducted a prospective observational study between January 2020 and December 2021, enrolling consecutive febrile patients hospitalized after the ED visit, and evaluating the association between the CREED score values and the IE diagnosis. A total of 15 689 patients (median age, 71 [56-81] years; 54.1% men) were enrolled in the retrospective cohort, and IE was diagnosed in 267 (1.7%). The CREED score included 12 variables: male sex, anemia, dialysis, pacemaker, recent hospitalization, recent stroke, chest pain, specific infective diagnosis, valvular heart disease, valvular prosthesis, previous endocarditis, and clinical signs of suspect endocarditis. The CREED score identified 4 risk groups for IE diagnosis, with an area under the receiver operating characteristic curve of 0.874 (0.849-0.899). The prospective cohort included 13 163 patients, with 130 (1.0%) IE diagnoses. The CREED score had an area under the receiver operating characteristic curve of 0.881 (0.848-0.913) in the validation cohort, not significantly different from the one calculated in the retrospective cohort (P=0.578). Conclusions In this study, we propose and prospectively validate the CREED score, a clinical prediction rule for the diagnosis of IE in patients with fever admitted to the ED. Our data reflect the difficulty of creating a meaningful tool able to identify patients with IE among this general and heterogeneous population because of the complexity of the disease and its low prevalence in the ED setting.

Repeated valve replacement: approaches and devices (literature review)

Bioprosthetic valve dysfunction represent a serious drawback that limits the wider clinical use of these medical devices for valvular heart disease surgery. Modern studies describe the view of pathophysiologists on this problem as a multifactorial multi-stage process that causes irreversible changes in bioprosthesis components, ultimately leading to its dysfunction. However, in addition to under- standing the causes and manifestations of prosthetic valve dys- function, an applied question arises about the treatment strategies — determining the most attenuated and accessible low-risk method/ device. The aim of this review was to analyze and systematize current literature data on methods and designs used in repeated surgical and transcatheter interventions on heart valves.

Cerebrovascular complications and outcomes of critically ill adult patients with infective endocarditis

BACKGROUND

Neurological complications are associated with poor outcome in patients with infective endocarditis (IE). Although guidelines recommend systematic brain imaging in the evaluation of IE patients, the association between early brain imaging findings and outcomes has never been evaluated in critically ill patients. We aimed to assess the association of CT-defined neurological complications with functional outcomes of critically ill IE patients.

METHODS

This retrospective cohort study included consecutive patients with severe, left-sided IE hospitalized in the medical ICU of a tertiary care hospital. Patients with no baseline brain CT were excluded. Baseline CT-scans were classified in five mutually exclusive categories (normal, moderate-to-severe ischemic stroke, minor ischemic stroke, intracranial hemorrhage, other abnormal CT). The primary endpoint was 1-year favorable outcome, defined by a modified Rankin Scale score of 0-3.

RESULTS

Between 06/01/2011 and 07/31/2018, 156 patients were included. Among them, 87/156 (56%) had a CT-defined neurological complication, including moderate-to-severe ischemic stroke (n = 33/156, 21%), intracranial hemorrhage (n = 24/156, 15%), minor ischemic stroke (n = 29/156, 19%), other (n = 3/156, 2%). At one year, 69 (45%) patients had a favorable outcome. Factors negatively associated with favorable outcome in multivariable analysis were moderate-to-severe ischemic stroke (OR 0.37, 95%CI 0.14 - 0.95) and age (OR 0.94, 95%CI 0.91-0.97). By contrast, the score on the Glasgow Coma Scale was positively associated with favorable outcome (per 1-point increment, OR 1.23, 95%CI 1.08-1.42). Sensitivity analyses conducted in operated patients revealed similar findings. Compared to normal CT, only moderate-to-severe ischemic stroke was associated with more frequent post-operative neurological complications (n = 8/23 (35%) vs n = 1/46 (2%), p < 0.01).

CONCLUSION

Moderate-to-severe ischemic stroke had an independent negative impact on 1-year functional outcome in critically ill IE patients; whereas other complications, including intracranial hemorrhage, had no such impact.

Staphylococcus aureus endocarditis: Identifying prognostic factors using a method derived from morbidity and mortality conferences

Objectives

Lethality of Staphylococcus aureus (Sa) infective endocarditis (IE) is high and might be due to yet unidentified prognostic factors. The aim of this study was to search for new potential prognostic factors and assess their prognostic value in SaIE.

Materials and methods

We used a two-step exploratory approach. First, using a qualitative approach derived from mortality and morbidity conferences, we conducted a review of the medical records of 30 patients with SaIE (15 deceased and 15 survivors), randomly extracted from an IE cohort database (NCT03295045), to detect new factors of possible prognostic interest. Second, we collected quantitative data for these factors in the entire set of SaIE patients and used multivariate Cox models to estimate their prognostic value.

Results

A total of 134 patients with modified Duke definite SaIE were included, 64 of whom died during follow-up. Of the 56 candidate prognostic factors identified at the first step, 3 had a significant prognostic value in multivariate analysis: the prior use of non-steroidal anti-inflammatory drugs [aHR 3.60, 95% CI (1.59-8.15), p = 0.002]; the non-performance of valve surgery when indicated [aHR 1.85, 95% CI (1.01-3.39), p = 0.046]; and the decrease of vegetation size on antibiotic treatment [aHR 0.34, 95% CI (0.12-0.97), p = 0.044].

Conclusion

We identified three potential SaIE prognostic factors. These results, if externally validated, might eventually help improve the management of patients with SaIE.

Origin of Sepsis Associated with the Short-Term Mortality of Patients: A Retrospective Study Using the eICU Collaborative Research Database

OBJECTIVE

The aim of this study was to compare the clinical characteristics and short-term mortality of patients with abdominal and pulmonary sepsis.

DESIGN

Retrospective cohort study.

SETTING

Adult intensive care units (ICUs) at tertiary hospitals.

PARTICIPANTS

Adult ICU patients from 2014 to 2015 in the eICU Collaborative Research Database.

INTERVENTIONS

In univariate analysis, we compared the differences in the characteristics of patients in each group. Logistic regression models were used to evaluate the relationships between primary site of sepsis and short-term prognosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

Hospital and ICU survival.

RESULTS

The final dataset included 7023 pulmonary and 2360 abdominal sepsis patients, who accounted for 74.84% and 25.16%, respectively. We compared the results of the baseline characteristics, vital signs and laboratory indicators between the two groups. In the logistic regression models, we found that the hospital and ICU mortality of patients with abdominal sepsis was higher than that with pulmonary sepsis (p < 0.05, OR = 1.15, p < 0.05, OR = 1.19, respectively), although these results were no longer significantly after adjustment for confounders, but in the subgroups with SOFA score ≧ 8, the adjusted hospital mortality rate of patients with abdominal sepsis was 1.30 times higher than that of patients with pulmonary sepsis (p < 0.005, OR = 1.30, 95% CI 1.09-1.55), while there was no significant difference in the subgroups that SOFA score < 8.

CONCLUSION

In the patients with SOFA score ≧ 8, the adjusted hospital mortality of patients with abdominal sepsis was higher than patients with pulmonary sepsis.

Outcomes and Risk Factors of Septic Shock in Patients With Infective Endocarditis: A Prospective Cohort Study

Background

Little is known about the characteristics and impact of septic shock (SS) on the outcomes of infective endocarditis (IE). We aimed to investigate the characteristics and outcomes of patients with IE presenting with SS and to compare them to those of IE patients with sepsis (Se) and those with neither Se nor SS (no-Se-SS).

Methods

This is a prospective cohort study of 4864 IE patients from 35 Spanish centers (2008 to 2018). Logistic regression analyses were performed to identify risk factors for SS and mortality.

Results

Septic shock and Se presented in 597 (12.3%) and 559 (11.5%) patients, respectively. Patients with SS were younger and presented significantly higher rates of diabetes, chronic renal and liver disease, transplantation, nosocomial acquisition, Staphylococcus aureus, IE complications, and in-hospital mortality (62.5%, 37.7% for Se and 18.2% for no-Se-SS, P < .001). Staphylococcus aureus (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.34–2.81; P < .001), Gram negative (OR, 2.21; 95% CI, 1.25–3.91; P = .006), nosocomial acquisition (OR, 1.44; 95% CI, 1.07–1.94; P = .015), persistent bacteremia (OR, 1.82; 95% CI, 1.24–2.68; P = .002), acute renal failure (OR, 3.02; 95% CI, 2.28–4.01; P < .001), central nervous system emboli (OR, 1.48; 95% CI, 1.08–2.01; P = .013), and larger vegetation size (OR, 1.01; 95% CI, 1.00–1.02; P. = 020) were associated with a higher risk of developing SS. Charlson score, heart failure, persistent bacteremia, acute renal failure, mechanical ventilation, worsening of liver disease, S aureus, and receiving aminoglycosides within the first 24 hours were associated with higher in-hospital mortality, whereas male sex, native valve IE, and cardiac surgery were associated with lower mortality.

Conclusions

Septic shock is frequent and entails dismal prognosis. Early identification of patients at risk of developing SS and early assessment for cardiac surgery appear as key factors to improve outcomes.

Infective endocarditis in patients with pyogenic spondylodiscitis: implications for diagnosis and therapy

OBJECTIVEThe incidence of patients with pyogenic spinal infection is increasing. In addition to treatment of the spinal infection, early diagnosis of and therapy for coexisting infections, especially infective endocarditis (IE), is an important issue. The aim of this study was to evaluate the proportion of coexisting IE and the value of routine transesophageal echocardiography (TEE) in the management of these patients.METHODSThe medical history, laboratory data, radiographic findings, treatment modalities, and results of TEE of patients admitted between 2007 and 2017 were analyzed.RESULTSDuring the abovementioned period, 110 of 255 total patients underwent TEE for detection of IE. The detection rate of IE between those patients undergoing and not undergoing TEE was 33% and 3%, respectively (p < 0.0001). Thirty-six percent of patients with IE needed cardiac surgical intervention because of severe valve destruction. Chronic renal failure, heart failure, septic condition at admission, and preexisting heart condition were significantly associated with coexisting IE. The mortality rate in patients with IE was significantly higher than in patients without IE (22% vs 3%, p = 0.002).CONCLUSIONSTEE should be performed routinely in all patients with spondylodiscitis.

Contemporary Trends in Native Valve Infective Endocarditis in United States (from the National Inpatient Sample Database)

Infective Endocarditis (IE) is associated with high mortality and morbidity. The data on contemporary trends and health care utilization remain scarce for IE. Consequently, we used the National Inpatient Sample database from 2002 to 2016 to study burden of IE. Risk-adjusted rates were calculated using an Analysis of Covariance with the Generalized Linear Model. Trends were assessed with linear regression and Pearson's Chi-square modeling, where appropriate. Binomial logistic regression was used for computing predictors of in-hospital mortality. We identified 523,432 hospitalizations for native valve IE. Risk-adjusted mortality decreased from 16.7% in 2002 to 9.7% in 2016 (p <0.01). The risk-adjusted length of stay decreased from 17.4 days in 2002 to 13.4 days in 2016 (p <0.01). Mean cost of stay adjusted for risk factors and inflation increased from 112,702$ in 2002 to 164,767$ in 2016 (p <0.01). Valve replacement increased from 10.2% in 2002 in to 13.4% in 2016, (p <0.01). Independent predictors of mortality included age (OR, 1.02 [1.02 to 1.020], p <0.01), female gender (OR, 1.07 [1.05 to 1.09], p <0.01), Blacks (OR, 1.28 [1.24 to 1.31], p <0.01), Hispanics (OR, 1.15 [1.11 to 1.19], p <0.01) and patients with co-morbid conditions like congestive heart failure (OR, 1.78 [1.74 to 1.82], p <0.01), renal failure (OR, [1.69 [1.65 to 1.73], p <0.01) and weight loss (OR, 1.40 [1.36 to 1.43], p <0.01). In summary, in-hospital mortality from native valve IE has been decreasing but total hospitalization and average cost of stay has increased.

Microbial aetiology of brain abscess in a UK cohort: Prominent role of Streptococcus intermedius

BACKGROUND

Brain abscess is an uncommon condition, but carries high mortality. Current treatment guidelines are based on limited data. Surveillance of clinical, radiological and microbiology data is important to inform patient stratification, interventions, and antimicrobial stewardship.

METHODS

We undertook a retrospective, observational study of patients with brain abscess, based on hospital coding, in a UK tertiary referral teaching hospital. We reviewed imaging data, laboratory microbiology, and antibiotic prescriptions.

RESULTS

Over a 47 month period, we identified 47 adults with bacterial brain abscess (77% male, median age 47 years). Most of the abscesses were solitary frontal or parietal lesions. A microbiological diagnosis was secured in 39/47 (83%) of cases, among which the majority were of the Streptococcus milleri group (27/39; 69%), with a predominance of Streptococcus intermedius (19/27; 70%). Patients received a median of 6 weeks of intravenous antibiotics (most commonly ceftriaxone), with variable oral follow-on regimens. Ten patients (21%) died, up to 146 days after diagnosis. Mortality was significantly associated with increasing age, multiple abscesses, immunosuppression and the presence of an underlying cardiac anomaly.

CONCLUSION

Our data suggest that there has been a shift away from staphylococcal brain abscesses, towards S. intermedius as a dominant pathogen. In our setting, empiric current first line therapy with ceftriaxone remains appropriate on microbiological grounds and narrower spectrum therapy may sometimes be justified. Mortality of this condition remains high among patients with comorbidity. Prospective studies are required to inform optimum dose, route and duration of antimicrobial therapy.

Infective endocarditis in French Polynesia: Epidemiology, treatments and outcomes

BACKGROUND

French Polynesia is a French overseas collectivity in the South Pacific Ocean, where data on infective endocarditis (IE) are lacking.

AIMS

To investigate the epidemiology and outcomes of IE in French Polynesia.

METHODS

All hospital records from consecutive patients hospitalized in Taaone Hospital, Tahiti, from 2015 to 2018, with an International Classification of Diseases, 10th revision, separation diagnosis of IE (I330), were reviewed retrospectively.

RESULTS

From 190 hospital charts reviewed, 105 patients with a final diagnosis of IE, confirmed according to the modified Duke criteria, were included. The median duration of follow-up was 71 days (interquartile range 18-163 days). The mean age was 55±17 years, and there were 68 men (65%). Thirty-five patients (33%) had a history of rheumatic carditis and 43 (41%) had a prosthetic valve. There were 40 (38%) cases of staphylococcal IE, 32 (30%) of streptococcal IE and six (6%) of enterococcal IE. Cardiogenic shock, septic shock and clinically relevant cerebral complications were strongly associated with death from any cause (hazard ratio [HR] 16.85, 95% confidence interval [CI] 5.45-52.05 [P<0.001]; HR 2.62, 95% CI 1.23-5.56 [P=0.01]; and HR 4.14, 95% CI 1.92-8.92 [P<0.001], respectively). Seventy-three patients (69%) had a theoretical indication for surgery, which was performed in 38 patients (36%). Lack of surgery when there was a theoretical indication was significantly associated with death (HR 6.93, 95% CI 3.47-13.83; P<0.0001).

CONCLUSIONS

The pattern of IE in French Polynesia differs from Western countries in many ways. Postrheumatic valvular disease remains the main underlying disease, and access to emergency heart surgery is still a challenge.

Risk Factors for Mortality in Patients Undergoing Cardiothoracic Surgery for Infective Endocarditis

BACKGROUND

This study aimed to identify risk factors associated with mortality of patients who undergo cardiac surgery for infective endocarditis.

METHODS

A retrospective review was performed of patients with infective endocarditis who underwent cardiac surgery at a quaternary Australian hospital between 2004 and 2014. Patient data were collected and prospectively analyzed.

RESULTS

In all, 465 patients underwent surgery during the study period, with 30 deaths (6.45%). Factors independently associated with in-hospital mortality were increasing age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01 to 1.07; P = .009), active bacterial endocarditis at time of operation (OR 4.91; 95% CI, 1.01 to 23.8; P = .048), preoperative invasive positive pressure ventilation (OR 3.65; 95% CI, 1.18 to 11.27; P = .025), increasing cardiopulmonary bypass time (OR 1.01; 95% CI, 1.006 to 1.014; P < .001), and increasing European System for Cardiac Operative Risk Evaluation score (OR 21.73; 95% CI, 2.12 to 223.11; P < .01).

CONCLUSIONS

The in-hospital mortality of patients with infective endocarditis remains significant, with potential risk factors including increasing age, active bacterial endocarditis, preoperative invasive positive pressure ventilation, increasing cardiopulmonary bypass time, and high European System for Cardiac Operative Risk Evaluation score.

Surgery for acute infective endocarditis: epidemiological data from a Spanish nationwide hospital-based registry

OBJECTIVES

Infective endocarditis (IE) is a serious and eventually lethal disease with rising incidence in the past couple of decades. The aim of this study was to evaluate the contemporary epidemiological trends of surgical endocarditis patients, to analyse the clinical outcomes and to study their profile, associated prognostic factors and costs.

METHODS

This is a retrospective study of all patients admitted for IE in Spanish hospitals and discharged between 1 January 1997 and 31 December 2014. Data were extracted from the minimum basic data set of the National Surveillance System for Hospital Data in Spain provided by the Spanish Ministry of Health. Hospitalizations, comorbidities, outcomes and costs were analysed.

RESULTS

In total, 34 399 patients with IE were included; 15.7% of patients received surgical treatment and 84.3% received medical treatment only. Surgical patients were mostly men (71.9%) and had a lower mean age (59.2 ± 16.08 years) than the medical treatment group (P < 0.0001). Mortality among surgical patients showed a decreasing trend between 1997 (32.0%) and 2014 (22.7%) and increased with age (47.6% in ≥85 years of age). Length of hospital stay and the percentage of patients with organ dysfunction were also higher in this group. The cost of the surgical treatment group was higher and increased since 1997 (15 259.22 euros), remaining stable from 2010 (40 700 euros) (P < 0.0001).

CONCLUSIONS

Surgical treatment in IE has trended upwards in Spain during the last 2 decades. Patients are getting older and more frequently experience organ dysfunction. Mortality ratio steadily declined without changes in the length of hospital stay.

Clinical Analysis of 161 Cases of Surgical Treatment of Infective Endocarditis

Objective: To evaluate the diagnostic criteria, surgical indications, and prognostic factors in the surgical treatment of infective endocarditis (IE). Methods: A total of 161 cases of post-operative IE treated at our hospital from January 2007 to December 2016 were included. The IE was diagnosed by the modified Duke criteria. Echocardiography and standard blood cultures were performed. These cases were divided into severe and non-severe adverse event groups. The association between prognostic factors and severe versus non-severe outcomes was examined using logistic regression. Results: Thirty patients (20.1%) with post-operative IE had positive pre-operative blood cultures, and 130 patients (80.7%) had valve vegetations. Four patients (2.5%) died within 30 days post-operatively. Twenty-two patients experienced severe adverse events. There were significant differences between the two groups regarding their serum albumin and creatinine concentrations, ejection fraction, and hospitalization, cardiopulmonary bypass, aortic cross-clamp, intensive care unit (ICU), and ventilation times (all p < 0.05). The bypass time, aortic cross-clamp time, and ICU time were identified as prognostic factors for severe adverse events. Conclusion: Echocardiography is an important diagnostic method for IE, and repeated tests might improve the sensitivity of diagnosis. Cardiac surgery seems to be an effective treatment for IE. Patient screening and reducing the operative time may improve the prognosis for patients who undergo surgical treatment for IE.

Epidemiology of infective endocarditis in French intensive care units over the 1997-2014 period-from CUB-Réa Network

Background

Few studies focus only on severe forms of infective endocarditis, for which organ failure requires admission to an intensive care unit (ICU). This study aimed to describe demographical, comorbidities, organ failure, and pathogen-related characteristics in a population of critically ill patients admitted to ICU for infective endocarditis and to identify risk factors of in-ICU mortality.

Methods

Retrospective observational multicenter (N = 34) study of the CUB-Rea register, based on ICD-10 coding rules, between 1997 and 2014 in France including ICU patients managed for infective endocarditis. In-ICU mortality associated factors were assessed by multivariate logistic regression including an interrupted time analysis of three periods (1997–2003, 2004–2009, and 2010–2014).

Results

Four thousand four hundred five patients admitted in ICU for infective endocarditis were included. We observed an increase in endocarditis prevalence, as well as an increase in organ failure severity over the three periods. In addition, valve surgery was more frequently performed (27%, 31%, and 42%, P < 0.0001) while in-ICU mortality significantly decreased (28%, 29%, and 23%, P < 0.001). Since 2010, a significant increase in the trends’ slope of incidence for Streptococcus sp. and Staphylococcus sp. was observed with no change concerning intracellular bacteria, Enterococcus sp. or Candida sp. slope trends. In multivariate analysis, age, SAPS2, organ failure, stroke, and Staphylococcus sp. were associated with ICU mortality. Conversely, surgery, intracardiac devices, male gender, and Streptococcus sp.-related infective endocarditis were associated with a better outcome.

Conclusions

Our study reveals a shifting landscape of infective endocarditis epidemiology in French ICUs, characterized by reduced in-ICU mortality despite higher severity, more surgery, and substantial changes in microbial epidemiology.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2387-8) contains supplementary material, which is available to authorized users.

[Infective Endocarditis Causing Native and Prosthetic Heart Valve Dysfunction]

Infective endocarditis (IE) is the disease that has high inhospital mortality. Heart valves dysfunction - both native and prosthetic - is the primary IE complication requiring a surgical intervention. The IE causes and its course have been discussed in this review. In particular, the role of concomitant infectious foci in the formation and development of IE have been considered, the mechanisms of mutual transition of subacute and acute clinical forms have been described. Modern diagnostic principles and methods based on the Duke criteria system have been mentioned, as well as the difficulties that follow the patient's clinical status evaluation. The normobiotic microbiota participation, as well as the possibilities for their identification using blood culture and PCR technique, have been closely reviewed. According to modern researches and publications, there have been made the conclusion about the contribution of obligate anaerobic bacteria, fungi and viruses to the development of endocarditis. There have been described the hypothesis about the presumptive strategy for the cardiac dysfunction formation as a result of the IE causative agents cells metabolic activity based on a literature data analysis in the article: vegetation formed by Staphylococcus aureus can lead to the heart valve stenosis, and the influence of hyaluronidases, collagenases on a heart valve structure can lead to regurgitation. The pathogens cells ability to avoid the human immune system response is caused by the biofilms, fibrin vegetations formation and the enzymes production - cytotoxins (streptolysins, leukocidin, etc.). It has been suggested that the mediators of inflammation and leukocyte cells participate in the destruction of native and prosthetic tissues due to an IE pathogens inaccessibility for immunocompetent cells.

Early results for active infective endocarditis

Introduction

Cardiac surgery is frequently needed during active phase of infective endocarditis (IE). The purpose of this study was to analyze the immediate and late results and determine the risk factors for death.

Methods

We retrospectively reviewed 101 patients with IE operated in the active phase. The mean age was 40.5 ± 12.5 years. 16 patients (15.8%) were diagnosed with prosthetic valve endocarditis (PVE). 81 (80.9%) were in NYHA functional class III-IV. Blood cultures were positive in only 24 cases (23.9%).

Results

in-hospital mortality rate was 17.9% (18 cases). Multivariate analysis indentified five determinant predictor factors: congestive heart failure (CHF), renal insufficiency, high Euroscore, prolonged cardiopulmonary bypass time (> 120 min) and long ICU stay. The median follow-up period was 4.2 (2-6.5) years. Overall survival rate for all patients who survived surgery was 97% at 5 years and 91% at 10 years.

Conclusion

Despite high in-hospital mortality rate, when patients receive operation early in the active phase of their illness, late outcome may be good.

Endophthalmitis and Mycotic Aneurysm: The Only Clues to Underlying Endocarditis

Infective endocarditis is a deadly disease that can present as a myriad of symptoms and thus its diagnosis can be missed. We present a case of infective endocarditis presenting as endogenous endophthalmitis and a ruptured mycotic aneurysm. This case illustrates both the complexity of infective endocarditis as a disease process and the more subtle diagnostic criteria as outlined by the Modified Duke Criteria.

Short- and long-term outcomes in infective endocarditis patients: a systematic review and meta-analysis

Background

Despite advances in medical knowledge, technology and antimicrobial therapy, infective endocarditis (IE) is still associated with devastating outcomes. No reviews have yet assessed the outcomes of IE patients undergoing short- and long-term outcome evaluation, such as all-cause mortality and IE-related complications. We conducted a systematic review and meta-analysis to examine the short- and long-term mortality, as well as IE-related complications in patients with definite IE.

Methods

A computerized systematic literature search was carried out in PubMed, Scopus and Google Scholar from 2000 to August, 2016. Included studies were published studies in English that assessed short-and long-term mortality for adult IE patients. Pooled estimations with 95% confidence interval (CI) were calculated with DerSimonian-Laird (DL) random-effects model. Sensitivity and subgroup analyses were also performed. Publication bias was evaluated using inspection of funnel plots and statistical tests.

Results

Twenty five observational studies (retrospective, 14; prospective, 11) including 22,382 patients were identified. The overall pooled mortality estimates for IE patients who underwent short- and long-term follow-up were 20% (95% CI: 18.0–23.0, P < 0.01) and 37% (95% CI: 27.0–48.0, P < 0.01), respectively. The pooled prevalence of cardiac complications in patients with IE was found to be 39% (95%CI: 32.0–46.0) while septic embolism and renal complications accounted for 25% (95% CI: 20.0–31) and 19% (95% CI: 14.0–25.0) (all P < 0.01), respectively.

Conclusion

Irrespective of the follow-up period, a significantly higher mortality rate was reported in IE patients, and the burden of IE-related complications were immense. Further research is needed to assess the determinants of overall mortality in IE patients, as well as well-designed observational studies to conform our results.

Electronic supplementary material

The online version of this article (10.1186/s12872-017-0729-5) contains supplementary material, which is available to authorized users.

Neurologic Complications of Infective Endocarditis: Recent Findings

PURPOSE OF REVIEW

The purpose of this paper is to provide recent insights in management of neurologic complications of left-sided infective endocarditis (IE).

RECENT FINDINGS

Cerebral lesions observed in IE patients are thought to involve synergistic pathophysiological mechanisms including thromboembolism, sepsis, meningitis, and small-vessel cerebral vasculitis. Brain MRI represents a major tool for the detection of asymptomatic events occurring in the majority of patients. The latter can impact therapeutic decisions and prognosis, especially when cardiac surgery is indicated. In patients presenting with neurologic complications, surgery could be safely performed earlier than previously thought. Symptomatic cerebral ischemic or hemorrhagic events occur in 20-55% of IE patients, whereas asymptomatic events are detected in 60-80% of patients undergoing systematic brain MRI. Management of such patients requires an experienced multidisciplinary team. Recent studies suggest that early cardiac surgery, when indicated, can be performed safely in patients with cerebral ischemic events. Other important issues include the appropriate use of anti-infective and anti-thrombotic agents, and endovascular treatment for mycotic aneurysms. Altered mental status at IE onset, which is associated with brain injury, is a major determinant of short-term outcome.

Innate Immune Memory Contributes to Host Defense against Recurrent Skin and Skin Structure Infections Caused by Methicillin-Resistant Staphylococcus aureus

Staphylococcus aureus is the leading cause of skin and skin structure infections (SSSI). The high frequency of recurring SSSI due to S. aureus, including methicillin-resistant S. aureus (MRSA) strains, despite high titers of specific antibodies and circulating T cells, implies that traditional adaptive immunity imparts incomplete protection. We hypothesized that innate immune memory contributes to the protective host defense against recurring MRSA infection. To test this hypothesis, SSSI was induced in wild-type and rag1^-/- mice in the BALB/c and C57BL/6 backgrounds. Prior infection (priming) of wild-type and rag1^-/- mice of either background afforded protection against repeat infection, as evidenced by reduced abscess severities and decreased CFU densities compared to those in naive controls. Interestingly, protection was greater on the previously infected flank than on the naive flank for wild-type and rag1^-/- mice. For wild-type mice, protective efficacy corresponded to increased infiltration of neutrophils (polymorphonuclear leukocytes [PMN]), macrophages (MΦ), Langerin⁺ dendritic cells (LDC), and natural killer (NK) cells. Protection was associated with the induction of interleukin-17A (IL-17A), IL-22, and gamma interferon (IFN-γ) as well as the antimicrobial peptides CRAMP and mβD-3. Priming also protected rag1^-/- mice against recurring SSSI, with increased MΦ and LDC infiltration and induction of IL-22, CRAMP, and mβD-3. These findings suggest that innate immune memory, mediated by specific cellular and molecular programs, likely contributes to the localized host defense in recurrent MRSA SSSI. These insights support the development of targeted immunotherapeutic strategies to address the challenge of MRSA infection.