Insights into microorganisms, associated factors, and the oral microbiome in infective endocarditis patients

Introduction

Infective Endocarditis (IE) is a rare, life-threatening infection of the endocardium with multisystem effects. Culprit microorganisms derived from different niches circulate through the bloodstream and attach to the endocardium, particularly the heart valves. This study aimed to investigate culprit microorganisms among a cross-sectional cohort of IE patients, their associated factors, and to explore the potential relationship to the oral microbiome.

Methods

In this observational study, we undertook a cross-sectional analysis of 392 medical records from patients diagnosed with IE. The primary outcome of this study was to analyse the association between the IE culprit microorganisms and the underlying anatomical types of IE (native valve (NVE), prosthetic valve (PVE), or cardiac device-related (CDE)). Secondary outcomes encompassed a comparative analysis of additional factors, including: the treatment approaches for IE, and the categorisation of blood cultures, extending to both genus and species levels. Additionally, we cross-referenced and compared the species-level identification of IE bacteraemia outcome measures with data from the expanded Human Oral Microbiome Database (eHOMD).

Results

A culprit microorganism was identified in 299 (76.28%) case participants. Staphylococcal infections were the most common (p < 0.001), responsible for 130 (33.16%) hospitalisations. There were 277 (70.66%) cases of NVE, 104 (26.53%) cases of PVE, and 11 (2.81%) cases of CDE. The majority of PVE occurred on prosthetic aortic valves (78/104, 75%), of which 72 (93.5%) were surgical aortic valve replacements (SAVR), 6 (7.8%) were transcatheter aortic valve implants, and one transcatheter pulmonary valve implant. Overall, underlying anatomy (p = 0.042) as well as the treatment approaches for IE (p < 0.001) were significantly associated with IE culprit microorganisms. Cross-reference between IE bacteraemia outcomes with the eHOMD was observed in 267/392 (68.11%) cases.

Conclusions

This study demonstrated that IE patients with a history of stroke, smoking, intravenous drug use, or dialysis were more likely to be infected with Staphylococcus aureus. CDE case participants and patients who had previous SAVR were most associated with Staphylococcus epidermidis. IE patients aged 78+ were more likely to develop enterococci IE than other age groups. Oral microorganisms indicated by the eHOMD are significantly observed in the IE population. Further research, through enhanced dental and medical collaboration, is required to correlate the presence of oral microbiota as causative factor for IE.

Public involvement in research: exploring periodontal and peri-implant health and disease in partnership with Perio@RLH patient forum members

Patients, carers and the public form an important partnership with the research community. By working alongside researchers, patients make a valuable contribution to all parts of the research cycle. This paper provides an opinion regarding public involvement in periodontal and peri-implant research and summarises the key points derived from a focus group that explored the topic of research in the conditions of periodontal and peri-implant health and disease. The partnership comprised forum members from the Royal London Hospital periodontics patient group (Perio@RLH) and a multidisciplinary team of researchers and clinicians.

PATIENT PERIOPERATIVE EXPERIENCE AT ST. BARTHOLOMEW'S DURING THE COVID-19 PANDEMIC

Introduction

The pressure of the global COVID-19 pandemic led to unprecedented changes in the delivery of healthcare services in a short period of time. Due to the nature of cardiothoracic surgery, there was an urgent need to adapt and continue delivery of services whilst maintaining patient and staff safety (1) St. Bartholomew's Hospital is a Cardiothoracic tertiary centre. The trust underwent mass redistribution of intensive care services and creation of a new hospital (The Nightingale) to manage the influx of COVID-19 patients. Therefore, the delivery of cardiothoracic perioperative services changed significantly, requiring online or telephone appointments for pre-op assessment clinic; strict no visitors policy and the need for patient self-isolation prior to hospital admission. Delivering perioperative care in this new environment was challenging and we wanted to investigate how these changes impacted the perioperative experiences of cardiothoracic patients during this time with the aim of improving any shortcomings identified.

Methods

Between 7-8th September 2020, all patients who were at least 48h post-procedure were given a self-administered paper questionnaire after verbal consent was obtained. This consisted of a total of eight structured and unstructured questions. These were analysed using simple frequency analysis and manual analysis respectively. Common themes were identified.

Results

51 patients completed the questionnaire - 39 cardiac and 12 thoracic patients. The main themes were pain and surviving the operation with concerns regarding family. 88% of patients positively recalled speaking to an anaesthetist face to face, with over half of these interaction being a day before their surgery. 92% felt meeting the anaesthetist was useful in addressing their worries and helped with anxiety. Information delivery regarding post-operative pain was an overwhelming theme and potential area for improvement. 88% of patients would recommend St. Bartholomew's hospital to friends and family. 64.8% who completed the question “Is there anything else you want to tell your anaesthetists or critical care doctors?” wanted to express their gratitude to all healthcare professionals involved in their care. Interestingly, a number of patients reported that they would like information about lifestyle changes and identified a potential window for signposting for more support.

Discussion

Unfortunately, there is little national or international data for direct comparison of our findings. Post-operative pain expectations can be further explored to establish whether more preoperative information surrounding analgesia is required. Anaesthetists should be aware that the perioperative period for major surgery is a teachable moment for potential lifestyle changes and could play an important part in utilising this opportunity. We hope that this simple questionnaire can provide healthcare staff a better insight into perioperative patient experience and the importance of preoperative provision of information. Despite significant changes during the pandemic, it is reassuring to know that the overall patient experience was positive.

Improving pre-operative medicines reconciliation

An audit of 143 surgical admissions showed that only 30% of general surgery and urology patients have complete medication charts on the day of surgery prior to going to theatre, compared to 94% of orthopaedic patients. This was despite having been seen previously in the pre-operative assessment clinic (POAC). These patients went to the wards post-operatively, where many then missed doses of their life-sustaining medications. Orthopaedic patients see a prescribing pharmacist in POAC who undertakes medicines reconciliation; this is performed by junior doctors for surgical patients.

We designed three interventions to improve drug chart completion by junior doctors, and gathered prospective data for 22 weeks in the POAC. We also recorded attendance of junior doctors in the POAC and reasons for absence. Daily and weekly percentages of drug chart completion were plotted on a run chart.

The baseline completion rate was 43%. This rose to 45% after the first and second interventions, and 51% after the third intervention. However, the completion rate remained markedly below our target of 94%. Junior doctors attended only 44% of POACs. They reported being “too busy to attend” 41% of the time, and could not be contacted on 11% of occasions.

Junior doctors reported that they were unable to attend to both unwell inpatients and the POAC, the latter seeming less of a priority. This was despite a rota allocating doctors to attend POAC sessions free from clinical or teaching commitments.

We were unable to increase the rate of drug chart completion with the resources available. We therefore recommend the employment of prescribing pharmacists in the POAC for general surgery and urology patients.