Early Diagnosis and Treatment in Infective Endocarditis: Challenges for a Better Prognosis

Early surgery to prevent embolic events in patients with infective endocarditis: a comprehensive review

BACKGROUND

Infective endocarditis (IE) is a dangerous and lethal illness with high mortality rates. One of the main indications for surgery according to the guidelines is prevention of embolic events. However, uncertainty remains concerning the timing of surgery and the effect of early surgery in combination with antibiotic therapy versus antibiotic therapy alone in IE patients with a vegetation size > 10 mm.

METHODS

We conducted a comprehensive review by searching the PubMed, MEDLINE, and EMbase databases. Titles and abstracts were screened, and studies of interest were selected for full-text assessment. Studies were selected for review if they met the criteria of comparing surgical treatment + antibiotic therapy to antibiotic therapy alone in patients with vegetations > 10 mm.

RESULTS

We found 1,503 studies through our database search; nine of these were eligible for review, with a total number of 3,565 patients. Median age was 66 years (range: 17-80) and the median percentage of male patients was 65.6% (range: 61.8 - 71.4%). There was one randomised controlled trial, one prospective study, and seven retrospective studies. Seven studies found surgery + antibiotic therapy to be associated with better outcomes in patients with IE and vegetations > 10 mm, one of them being the randomised trial [hazard ratio = 0.10; 95% confidence interval 0.01-0.82]. Two studies found surgery + antibiotic therapy was associated with poorer outcomes compared with antibiotic therapy alone.

CONCLUSION

Overall, data vary in quality due to low numbers and selection bias. Evidence is conflicting, yet suggest that surgery + antibiotic therapy is associated with better outcomes in patients with IE and vegetations > 10 mm for prevention of emboli. Properly powered randomised trials are warranted.

Case report: Diagnostic and therapeutic challenges of fungal endocarditis by Trichosporon asahii in a child with congenital heart defects

Background

patients with congenital cardiopathies are the main group at risk for infective endocarditis (IE) in the pediatric population. Fungal etiology is responsible for 2%-4% of all IEs, and the Trichosporon genus is an increasingly prevalent cause of infections in human beings.

Case presentation

We describe a 9-year-old male with multiple surgical procedures to correct congenital cardiopathy defects, including insertion of RV-PA conduit, who was admitted due to suspicion of pneumonia and needed a surgical approach after being diagnosed with a mycotic pseudoaneurysm in the right ventricle's outflow tract, with dilation of the RV-PA conduit. The conduit was removed and antifungal treatment was started with Voriconazole after the agent was identified (T. asahii), with satisfactory therapeutic response. Approximately 4 years later, the patient was readmitted, presenting with intermittent fever, associated with nocturnal diaphoresis, dry cough, anxiety and chest pain. Vegetations consistent with T. asahii were evidenced in the RV-PA conduit, and a surgical approach was once again necessary.

Discussion

diagnostic methods and treatment of T. asahii endocarditis aren't yet standardized, and recurrent surgical approaches are needed due to the inefficacy of antifungal treatment.

Predictors of Complications Secondary to Infective Endocarditis and Their Associated Outcomes: A Large Cohort Study from the National Emergency Database (2016-2018)

Introduction

Literature regarding outcomes and predictors of complications secondary to infective endocarditis (IE) is limited. We aimed to study the outcomes and predictors of complications of IE.

Methods

Data from a national emergency department sample, which constitutes 20% sample of hospital-owned emergency departments in the USA, were analyzed for hospital visits for IE. Complications of endocarditis were obtained by using ICD codes. Multivariable generalized linear method was used to evaluate predictors of in-hospital mortality and complications.

Results

Out of 255,838 adult IE patients (mean age 60.3 ± 20.1 years, 48.5% females), 97,803 (38.2%) patients developed one or more major complications. The major complications were cardiovascular system complications [57,900 (22.6%)], neurologic [42,851 (16.7%)] complications, and renal [16,236 (6.4%)] complications. These included cardiogenic shock [3873 (1.5%)], septic shock [25,798 (10.1%)], acute heart failure [35,602 (14%)], systemic thromboembolism (STE) [21,390 (8.36%)], heart block [11,430 (4.47%)], in-hospital dialysis [2880 (1.1%)], and disseminated intravascular coagulation (DIC) [2704 (1.1%)]. Patients with complicated IE had risk of mortality (adjusted RR 1.12, 95% CI 1.11–1.13, p < 0.001). The complications strongly associated with mortality were septic shock (RR 1.29, 95% CI 1.27–1.30, p < 0.001), cardiogenic shock (RR 1.24, 95% CI 1.20–1.29, p < 0.001), DIC (RR 1.4, 95% CI 1.35–1.46, p < 0.001), and STE (RR 1.07, 95% CI 1.05–1.08, p < 0.001). Staphylococci were the predominant causative organisms (30.8%) among the complicated IE subgroups with higher associated mortality (42.8%). The main predictors of complications from IE were congenital heart disease, history of congestive heart failure, high Elixhauser comorbidity profile, staphylococcal infection, and fungal infections. The prevalence of cardiogenic shock increased over the study years from 1.13 to 1.98% (p-trend 0.04).

Conclusion

Complicated IE is not uncommon and is associated with significant mortality. Staphylococcal infections were associated with high mortality rates. There has been an increasing trend of cardiogenic shock among IE patients across the US. Further research is needed to improve the outcomes of complicated endocarditis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00563-y.

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.

Infective Endocarditis Masked by Narrow Focus Thinking, Inadequate Physical Examination and Analgesic Medication

It is important not to miss a diagnosis of infective endocarditis. It is fatal if untreated and most often successfully treatable if recognized. We report a classic case of subacute bacterial endocarditis with Osler nodes and Janeway lesions due to viridans streptococci from an oral source of poor dentition, infecting a presumably abnormal mitral valve. The diagnosis was missed repeatedly by multiple different clinicians over the course of seven months. Detailed analysis of this case suggests some of the pitfalls that led to the delay in diagnosis. The infective endocarditis was masked by analgesic medication, inadequate physical examination, and narrow focus thinking. The images of this case can serve as a reminder of the features of infective endocarditis. The detailed history and discussion can provide potential lessons in how to not miss the diagnosis of infective endocarditis.