Current Views on Infective Endocarditis: Changing Epidemiology, Improving Diagnostic Tools and Centering the Patient for Up-to-Date Management

Epidemiological, clinical and microbiological aspects of infective endocarditis in Türkiye

PURPOSE

Infective endocarditis (IE) is a evolving disease with a shifting epidemiology and disease burden over time. This study aimed to compare the epidemiological and clinical aspects of IE over three time periods across eleven years.

METHODS

This was a retrospective cohort, multicenter study conducted in Türkiye, comparing three periods: 2013-2016, 2017-2020, and 2021-2023. Epidemiological and microbiological characteristics, as well as patient outcomes, were analyzed and compared across these periods.

RESULTS

A total of 1,044 patients diagnosed with IE were included. The median (Q1-Q3) age was 57 (44-68) years, with an increasing pattern (p < 0.001). Throughout the study period, the prevalence of intracardiac devices increased, whereas the prevalence of degenerative and congenital heart diseases declined. Among all patients, the most frequently identified pathogens were staphylococci (36.4%), followed by streptococci (14.0%) and enterococci (11.9%). Throughout the three periods, there was a significant increase in staphylococci, with S. aureus emerging as the predominant pathogen in all type IE. The in-hospital mortality rate among all patients was 22.5%. Independent risk factors for in-hospital mortality included ≥ 65 age(OR = 1.9), chronic kidney disease (OR = 1.9), nosocomial acquisition (OR = 2.1), Candida spp. infection (OR = 2.9), prosthetic valve IE (OR = 1.9), vegetation size > 15 mm (OR = 1.6), and central nervous system emboli (OR = 2).

CONCLUSION

The epidemiology of IE is undergoing significant changes, leading to shifts in microbiological profiles and clinical presentations. Effective management of IE should be guided by established clinical guidelines while integrating up-to-date epidemiological data to ensure comprehensive and evidence-based patient care.

Staphylococcus aureus in Inflammation and Pain: Update on Pathologic Mechanisms

Staphylococcus aureus (S. aureus) is a Gram-positive bacterium of significant clinical importance, known for its versatility and ability to cause a wide array of infections, such as osteoarticular, pulmonary, cardiovascular, device-related, and hospital-acquired infections. This review describes the most recent evidence of the pathogenic potential of S. aureus, which is commonly part of the human microbiota but can lead to severe infections. The prevalence of pathogenic S. aureus in hospital and community settings contributes to substantial morbidity and mortality, particularly in individuals with compromised immune systems. The immunopathogenesis of S. aureus infections involves intricate interactions with the host immune and non-immune cells, characterized by various virulence factors that facilitate adherence, invasion, and evasion of the host's defenses. This review highlights the complexity of S. aureus infections, ranging from mild to life-threatening conditions, and underscores the growing public health concern posed by multidrug-resistant strains, including methicillin-resistant S. aureus (MRSA). This article aims to provide an updated perspective on S. aureus-related infections, highlighting the main diseases linked to this pathogen, how the different cell types, virulence factors, and signaling molecules are involved in the immunopathogenesis, and the future perspectives to overcome the current challenges to treat the affected individuals.

Routine HIV Testing for People Who Inject Drugs Hospitalized With Infective Endocarditis in the United States: A Commentary

ABSTRACT

HIV screening is not routinely offered to acutely ill, hospitalized patients. For some patients a hospitalization represents a crucial opportunity to identify undiagnosed HIV infection and interrupt HIV transmission chains. Among people who inject drugs, a hospitalization for infective endocarditis may be one of the only touchpoints they have with a health care provider. Nurse-led HIV screening initiatives in the acute care and emergency medicine settings are being trialed across the United States. Nurses and nurse practitioners are uniquely poised to establish universal, comprehensive HIV testing protocols for people who inject drugs hospitalized for the management of infective endocarditis.

A Rare Case of Infective Endocarditis with Recurrent Fever Caused by Elizabethkingia anophelis

Background

Elizabethkingia anophelis, an opportunistic pathogen that can cause infections in multiple parts of the human body, has multiple drug resistance and a high mortality rate. However, there have been few reports of infective endocarditis (IE) caused by Elizabethkingia anophelis, which means that diagnosis and treatment face challenges that cannot be ignored. Rapid and accurate identification and drug sensitivity results are needed to make timely treatment adjustments.

Case Presentation

An 81-year-old man presented with recurrent fever and increased infection index for more than a month. Based on his clinical symptoms, infection index, reduplicative blood cultures, and results of transesophageal echocardiography, he was ultimately diagnosed with infective endocarditis caused by Elizabethkingia anophelis. The patient had a favorable outcome with a 6-week course of intravenous antibiotic therapy.

Conclusion

This is a rare and successfully cured case of IE caused by the pathogen of Elizabethkingia anophelis, which is difficult not only in diagnosis but also in treatment. This case provides a certain referential significance to the treatment of Elizabethkingia anophelis-caused IE in clinical practice.

Impact of Psoas Muscle Area Index on Short- and Mid-Term Mortality in Patients Undergoing Valve Surgery for Infective Endocarditis: A Retrospective Analysis

Background: Sarcopenia, characterized by the loss of skeletal muscle mass, is an emerging comorbidity associated with poor outcomes in cardiovascular surgery. Its impact on mortality in patients undergoing valve surgery for infective endocarditis (IE) remains underexplored. This study investigates the relationship between sarcopenia, measured by the Psoas muscle area index (PMAi), and mortality in patients with IE undergoing valve surgery. Materials and Methods: We retrospectively analyzed 68 patients with IE who underwent valve surgery at a tertiary care center from 2013 to 2021. Sarcopenia was defined as being in the lowest quartile of PMAi, measured via preoperative computed tomography (CT). Baseline characteristics, survival outcomes, and factors influencing mortality were analyzed using Kaplan-Meier survival curves and Cox proportional hazards regression. The predictive value of PMAi for 1-year and 3-year mortality was assessed via receiver operating characteristic (ROC) curves. Results: Sarcopenia was strongly associated with increased mortality at both 1-year (HR: 0.378, p = 0.010) and 3-year follow-ups (HR: 0.457, p = 0.012). Female sex (OR: 275.748, p < 0.001) and older age (OR: 9.995, p = 0.003) were significant predictors of sarcopenia. Chronic kidney insufficiency (CKI) and the use of heart failure medication therapy also significantly impacted survival outcomes. Conclusions: Sarcopenia is a strong independent predictor of short- and mid-term mortality in patients undergoing valve surgery for IE. Routine radiological assessment of sarcopenia using PMAi could improve risk stratification and guide preoperative interventions. Tailored management strategies, especially in older women and patients with CKI, may enhance outcomes in this high-risk population.

Infective Endocarditis by Listeria Species-A Systematic Review

Infective endocarditis (IE) is a disease associated with significant morbidity and mortality. It is more commonly caused by Gram-positive cocci, but Gram-positive bacilli may seldom cause the disease. Listeria monocytogenes is an aerobic Gram-positive coccobacillus and a foodborne and opportunistic pathogen most commonly causing gastrointestinal infections, even though bacteremia, sepsis, meningitis, and fetal infections may also occur. Listeria IE has rarely been described, with most reports being case reports or case series. Thus, the characteristics of this disease remain largely unknown. This systematic review aimed to present all published Listeria IE studies and describe their characteristics. A search of PubMed, Scopus, and the Cochrane Library for studies providing information on epidemiology, clinical findings, treatment, and outcome of Listeria IE cases was performed. A total of 54 studies containing data from 62 patients were included. Among all patients, 64.5% were male; the median age was 69 years. Among all patients, 54.8% had a history of a prosthetic valve. The aortic valve was the most commonly affected, followed by the mitral. Fever, heart failure, and embolic phenomena were the most commonly encountered clinical findings. The only isolated species was L. monocytogenes. Antimicrobial resistance was relatively low for aminopenicillins and aminoglycosides, the most commonly used antimicrobials for treating L. monocytogenes IE. Surgery was performed in 27.4% of patients. Mortality was 37.1%. Patients who survived were more likely to have had a prosthetic valve, to have necessitated transesophageal echocardiography for the diagnosis, to have mitral valve IE, and to have had surgical management; however, no factor was identified in a multivariate logistic regression model as an independent factor for overall mortality.

Mitral valve infective endocarditis as a manifestation of disseminated Cryptococcus neoformans infection: a case report

Infective endocarditis is a disease that affects mainly the endocardial surface of the heart and cardiac valves (native or prosthetic). The main risk factors for developing infective endocarditis are male sex, older age, intracardiac shunts, prosthetic valves, rheumatic, and congenital heart disease, intracardiac devices, intravenous drugs use, immunosuppression, and hemodialysis. Streptococci and Staphylococci spp. have been the most frequent isolated organisms. On the other hand, the most common fungal organism in infective endocarditis is Candida albicans (24-46%), followed by Aspergillus spp. (25%), and a few cases by Cryptococcus neoformans, which are associated with higher rate of mortality. This case provides an interesting case of Cryptococcus neoformans native valve infective endocarditis in a young woman with stage IV chronic kidney disease and severe malnutrition.

Predictors of Mortality in Patients with Cardiac Device-Related Infective Endocarditis

Infective endocarditis (IE) associated with implantable cardiac devices (ICD) is a serious disease with high mortality rates. The increased number of ICD implants has led to increased ICD infection rates. The aim of this study was to characterize clinical, laboratory profiles and the prognosis of cardiac-device-related endocarditis (CDIE), as well as to identify predictors of in-hospital death. A total of 274 patients with IE were included in a prospective cohort (2007-2019). From these, 82 patients (30%) had CDIE (46 pacemakers, 23 cardioverter defibrillators, and 13 cardiac resynchronization therapy devices). Predisposed conditions; clinical, laboratory and echocardiographic parameters; etiologic agents; and in-hospital outcomes were evaluated. The mean age was 55.8 ± 16.4 years, where 64.6% were male. Among the clinical manifestations at diagnosis, the most prevalent were heart failure (67.9%), fever (60.5%), anorexia/hyporexia (44.4%), and heart murmur (37.5%). The median serum C-reactive protein (CRP) level at diagnosis was 63 mg/L (interquartile range [IQR] 20-161). Etiological agents were identified through positive blood cultures in 55% of cases. The main etiologic agents were negative-coagulase staphylococci (19.5%) and Staphylococcus aureus (18.3%). Vegetation was identified in 74 patients (90.1%). In-hospital mortality was 28%. CRP concentrations at diagnosis were identified as markers of disease severity (odds ratio [OR] 1.006; 95%CI 1.001-1.011; p = 0.016), and the worsening of heart failure was associated with unfavorable outcomes (OR 3.105; 95%CI 1.397-6.902; p = 0.005). Unlike what is traditionally accepted, CDIE does not have a better prognosis.

Publication Trends on Infective Endocarditis: Comprehensive Bibliometric Analysis and Visualization Between 1892 and 2022

BACKGROUND

In recent years, studies reported that the incidence of infective endocarditis (IE) has increased despite the decrease in rheumatic heart diseases, great advances in medical and surgical treatment methods, and prophylactic antibiotic therapies. However, there is no bibliometric analysis based on the visual mapping method in the literature. In the study, we aimed to analyze the hot topics in IE, the distribution of publications in terms of country, institution, journal, author, and their relationships by assessing IE articles published in the 130 years between 1892 and 2022.

METHODS

Publications before 2023 were analyzed using the keywords 'infective' and 'endocarditis' in the Scopus database.

RESULTS

Approximately 25% of the publications on IE were from the USA followed by Japan, France, and the UK. A total of 116 keywords were used at least 15 times and the keywords were categorized into 9 clusters by the VOSviewer program. The keywords used more than 100 times except 'infective endocarditis' were 'echocardiography,' 'mortality,' 'surgery,' 'Staphylococcus aureus,' 'cardiac surgery,' 'epidemiology,' and 'prognosis' 247, 191, 152, 142, 130, 122, and 119 times, respectively. To the best of our knowledge, the study is the most comprehensive study globally on IE with the widest time range including the visual mapping method.

CONCLUSION

Since our study reveals the changes in the literature related to infective endocarditis, we think that it will be a guide in planning new research studies. We believe that periodic repetition of bibliometric analyses and keyword mapping studies will contribute to the quantitative and qualitative development of scientific productivity globally.

Infection remediation after septic device extractions: analysis of three treatment strategies including a 1-year follow-up

Introduction

In CIED infections, all device material needs to be removed. But, especially in pacemaker-dependent patients it is often not possible to realize a device-free interval for infection remediation. In those patients, different treatment options are available, however the ideal solution needs still to be defined.

Methods

This retrospective analysis includes 190 patients undergoing CIED extractions due to infection. Three different treatment algorithms were analyzed: Group 1 included 89 patients with system removal only (System removal group). In Group 2, 28 patients received an epicardial electrode during extraction procedure (Epicardial lead group) while 78 patients in group 3 (contralateral reimplantation group) received implantation of a new system contralaterally during extraction procedure. We analyzed peri- and postoperative data as well as 1-year outcomes of the three groups.

Results

Patients in the system removal and epicardial lead groups were significantly older, had more comorbidities, and suffered more frequently from systemic infections than those in contralateral reimplantation group. Lead extraction procedures had comparable success rates: 95.5%, 96.4%, and 93.2% of complete lead removal in the System removal, Epicardial Lead, Contralateral re-implantation group respectively. Device reimplantation was performed in all patients in Epicardial lead and Contralateral reimplantation group, whereas only 49.4% in System removal group received device re-implantation. At 1-year follow-up, freedom from infection and absence of pocket irritation were comparable for all groups (94.7% Contralateral reimplantation group and Epicardial lead group, 100% System removal group). No procedure-related mortality was observed, whereas 1-year mortality was 3.4% in System removal group, 4.1% in Contralateral re-implantation group and 21.4% in Epicardial lead group (p < 0.001).

Conclusion

In patients with CIED infection, systems should be removed completely and reimplanted after infection remediation. In pacemaker-dependent patients, simultaneous contralateral CIED re-implantation or epicardial lead placement may be performed, depending on route, severity and location of infection.

Infective Endocarditis by Lactobacillus Species-A Narrative Review

Bacteria of the genus Lactobacillus are microaerophilic or aerotolerant anaerobic Gram-positive non-spore-forming rods. They are considered essential members of the human gut microbiome; however, recent studies have revealed that these microorganisms are less predominant in the gut microbiome than initially thought. Lactobacillus spp. is mainly known for its use as a probiotic in foods and supplements to prevent and treat specific issues such as infectious diseases, irritable bowel syndrome, and diabetes mellitus. However, Lactobacillus spp. may occasionally cause infections such as bacteremia or infective endocarditis (IE). The present study aimed to review all cases of IE by Lactobacillus spp. and describe the epidemiology, microbiology, clinical characteristics, treatment, and outcomes of this infection by collecting relevant data from studies existing in Pubmed and Scopus until 28 September 2023. A total of 77 studies containing data for 82 patients were included. The median age was 56 years, and 69.6% were male. A prosthetic valve was present in 16% of patients, and 17.3% had previously been on probiotics. The aortic valve was the most commonly involved intracardiac site, followed by the mitral valve. Fever, embolic phenomena, sepsis, and heart failure were the most common clinical presentations. Aminoglycosides and penicillin were the most commonly used antimicrobials for definitive treatment. Surgery was performed in 53.7% of patients. Overall mortality was 17.1%. IE in prosthetic valves and presentation with shock were independently associated with overall mortality.

Multimodality Imaging Diagnosis in Infective Endocarditis

Imaging is an important tool in the diagnosis and management of infective endocarditis (IE). Echocardiography is an essential examination, especially in native valve endocarditis (NVE), but its diagnostic accuracy is reduced in prosthetic valve endocarditis (PVE). The diagnostic ability is superior for transoesophageal echocardiography (TEE), but a negative test cannot exclude PVE. Both transthoracic echocardiography (TTE) and TEE can provide normal or inconclusive findings in up to 30% of cases, especially in patients with prosthetic devices. New advanced non-invasive imaging tests are increasingly used in the diagnosis of IE. Nuclear medicine imaging techniques have demonstrated their superiority over TEE for the diagnosis of PVE and cardiac implantable electronic device infective endocarditis (CIED-IE). Cardiac computed tomography angiography imaging is useful in PVE cases with inconclusive TTE and TEE investigations and for the evaluation of paravalvular complications. In the present review, imaging tools are described with their values and limitations for improving diagnosis in NVE, PVE and CIED-IE. Current knowledge about multimodality imaging approaches in IE and imaging methods to assess the local and distant complications of IE is also reviewed. Furthermore, a potential diagnostic work-up for different clinical scenarios is described. However, further studies are essential for refining diagnostic and management approaches in infective endocarditis, addressing limitations and optimizing advanced imaging techniques across different clinical scenarios.

Bloodstream Infection Due to Coagulase-Negative Staphylococci: Impact of Species on Prevalence of Infective Endocarditis

(1) Background: Coagulase-negative staphylococci (CoNS) are an important group of organisms that can cause bloodstream infection (BSI) and infective endocarditis (IE). The prevalence of IE in patients with BSI due to different CoNS species, however, has received limited attention; (2) Methods: A retrospective study of adults with monomicrobial CoNS BSI who had undergone echocardiography and a risk factor analysis was done to determine the most common CoNS species that cause definite IE; (3) Results: 247 patients with CoNS BSI were included in the investigation; 49 (19.8%) had definite IE, 124 (50.2%) possible IE, and 74 (30.0%) BSI only. The latter two entities were grouped in one category for further analysis. The most common species in CoNS BSI was Staphylococcus epidermidis (79.4%) and most patients (83.2%) had possible IE/BSI only. 59.1% of patients with BSI due to S. lugdunensis had definite IE. The majority of CoNS were healthcare-associated/nosocomial bacteremia. Multivariable analysis demonstrated that valve disease (p = 0.002) and a foreign cardiovascular material (p < 0.001) were risk factors associated with definite IE. Patients with S. lugdunensis BSI had an 8-fold higher risk of definite IE than did those with S. epidermidis BSI and nearly a 13-fold higher risk than did patients with BSI due to other species of CoNS (p = 0.002); (4) Conclusions: The prevalence of definite IE in patients with BSI due to different CoNS species was significant. CoNS bacteremia, particularly with S. lugdunensis, confers a significant risk of IE, particularly in patients with a valve disease or intravascular foreign body material and should not be immediately dismissed as a contaminant.

An Unusual Case of a Double Tricuspid and Mitral Valves Infective Endocarditis Complicated by Multiple Septic Embolisms Secondary to an Atrial Septal Defect: A Case Report and Review of Literature

Multivalvular endocarditis (MVE) is an uncommon infection that mostly involves mitral and aortic valves, and it is related to a higher risk of congestive heart failure and a higher mortality. We described a case of a bilateral MVE and performed a review of the literature on similar clinical cases. We reported an unusual case of a 68-year-old male patient with a tricuspid and mitral infective endocarditis due to a methicillin-resistant Staphylococcus aureus complicated by multiple right- and left-sided septic embolization (lungs, brain, spleen, L2-L3 vertebral bones) due to an unknown atrial septal defect identified and repaired during cardiac surgery. Despite the severity of the clinical case, the patient experienced a good clinical outcome also thanks to a multidisciplinary approach. We identified 21 case reports describing bilateral MVE. A multidisciplinary approach is essential in the management of valve diseases to improve the prognosis of patients, especially in bilateral MVE.