"A contemporary description of staphylococcus aureus prosthetic valve endocarditis. Differences according to the time elapsed from surgery"

Staphylococcus aureus prosthetic valve endocarditis (SAPVE) has a poor prognosis. There are no large series that accurately describe this entity.This is a retrospective observational study on a prospective cohort from 3 Spanish reference hospitals for cardiac surgery, including 78 definitive episodes of left SAPVE between 1996 and 2016.Fifty percent had a Charlson Index score >5; 53% were health care-related. Twenty percent did not present fever. Complications at diagnosis included: severe heart failure (HF, 29%), septic shock (SS, 17.9%), central nervous system abnormalities (19%), septic metastasis (4%). Hemorrhagic stroke was not higher in anticoagulated patients. Twenty-seven percent were methicilin-resistant SA (MRSA). Fifteen of 31 had positive valve culture; it was related to surgery within first 24 hours. At diagnosis, 69% had vegetation (>10 mm in 75%), 21.8% perianular extension, and 20% prosthetic dehiscence. Forty-eight percent had persistent bacteremia, related to nonsurgical treatment. Perianular extension progressed in 18%. Surgery was performed in 35 episodes (12 with stroke). Eleven uncomplicated episodes were managed with medical therapy, 8 survived. In-hospital mortality was 55%, higher in episodes with hemorrhagic stroke (77.8% vs 52.2%, odds ratio 3.2 [0.62-16.55]). Early SAPVE was nosocomial (92%), presented as severe HF (54%), patients were diagnosed and operated on early, 38% died. In intermediate SAPVE (9 weeks-1 year) diagnosis was delayed (24%), patients presented with constitutional syndrome (18%), renal failure (41%), and underwent surgery >72 hours after indication; 53% died. Late SAPVE (>1 year) was related with health care, diagnosis delay, and 60% of deceases.Left SAPVE frequently affected patients with comorbidity and health care contact. Complications at diagnosis and absence of fever were frequent. Presence of MRSA was high. Positive valve culture was related to early surgery. Paravalvular extension was frequent; vegetations were large, but its absence at diagnosis was common. Some uncomplicated SAPVE episodes were safety treated with medical therapy. Surgery was feasible in patients with stroke. Mortality was high. There were differences in some clinical characteristics and in evolution according to the time elapsed from valve replacement. Prognosis was better in early SAPVE.

Initial clinical outcomes and prognostic variables in the implementation of a Code Sepsis in a high complexity University Hospital

OBJECTIVE

To assess the impact of the first months of application of a Code Sepsis in a high complexity hospital, analyzing patient´s epidemiological and clinical characteristics and prognostic factors.

METHODS

A long-term observational study was carried out throughout a consecutive period of seven months (February 2015 - September 2015). The relationship with mortality of risk factors, and analytic values was analyzed using uni- and multivariate analyses.

RESULTS

A total of 237 patients were included. The in-hospital mortality was 24% at 30 days and 27% at 60 days. The mortality of patients admitted to Critical Care Units was 30%. Significant differences were found between the patients who died and those who survived in mean levels of creatinine (2.30 vs 1.46 mg/dL, p <0.05), lactic acid (6.10 vs 2.62 mmol/L, p <0.05) and procalcitonin (23.27 vs 12.73 mg/dL, p<0.05). A statistically significant linear trend was found between SOFA scale rating and mortality (p<0.05). In the multivariate analysis additional independent risk factors associated with death were identified: age > 65 years (OR 5.33, p <0.05), lactic acid > 3 mmol/L (OR 5,85, p <0,05), creatinine > 1,2 mgr /dL (OR 4,54, p <0,05) and shock (OR 6,57, P <0,05).

CONCLUSIONS

The epidemiological, clinical and mortality characteristics of the patients in our series are similar to the best published in the literature. The study has identified several markers that could be useful at a local level to estimate risk of death in septic patients. Studies like this one are necessary to make improvements in the Code Sepsis programs.

Relevance of clinical presentation and period of diagnosis in prosthetic valve endocarditis

BACKGROUND AND AIM OF THE STUDY

The study aim was to describe the characteristics of prosthetic valve endocarditis (PVE) and the clinical presentation in relation to the period of diagnosis.

METHODS

In this observational, prospective, multicenter study, data acquired from 100 consecutive cases of PVE were recorded. The period of diagnosis was defined as the time elapsed from valve implantation surgery to the PVE diagnosis. PVE was classified as early (EPVE) if diagnosed during the first eight weeks, intermediate (IPVE) from nine weeks to one year, and late (LVPE) if diagnosed after one year. Variables related to the period of diagnosis and causal microorganisms were compared using a chi-square test. A logistic regression analysis was made for any diagnosis delay greater than 15 days from the first symptoms, periannular extension, surgery, and death during hospitalization.

RESULTS

In total, data were collected from 24 patients with EPVE, 29 with IPVE, and 47 with LPVE. Some 59% of the IPVE episodes were caused by low-virulence microorganisms, compared to 29% of the EPVE episodes and 28% of the LPVE episodes (p = 0.017). Similarly, 66% of the IPVE episodes had a diagnosis delay longer than 15 days compared to 50% for LPVE and 20% for EPVE (p = 0.034), while 38% of the EPVE cases presented with fever and severe dyspnea compared to 10% of IPVE and 4% of LPVE cases (p = 0.001). In addition, 24% of the IPVE cases presented as fever and cardiac conduction disturbances, versus 4% for EPVE and 11% for LPVE (p = 0.08). When comparing EPVE with IPVE, the latter had a 69% periannular extension versus 38% for EPVE (p = 0.02) and 48% mortality versus 25%, respectively (p = 0.082). In a multivariate analysis, IPVE was related to the periannular extension of infection compared to EPVE (OR 3.4, 95% CI 0.98-12.1, p = 0.054). Death depended on the periannular extension of infection (OR 3.4, 95% CI 1.3-8.8, p = 0.011) and septic shock during hospitalization (OR 6.9, 95% CI 2.0-23.7, p = 0.002).

CONCLUSION

When diagnosed between nine weeks and one year after valve implantation, IPVE presented with low-grade clinical manifestations, a greater delay in diagnosis, a longer periannular extension and a poorer prognosis than did EPVE.

Chronic prosthetic valve endocarditis due to Propionibacterium acnes: an unexpected cause of prosthetic valve dysfunction

INTRODUCTION AND OBJECTIVES

To determine the characteristics of Propionibacterium acnes prosthetic valve endocarditis (PAPVE).

METHODS

Prospective descriptive study of 16 consecutive cases of PAPVE.

RESULTS

Seven patients developed PAPVE early and 9 developed it late. In all those who developed PAPVE late, there was a history of mucocutaneous barrier manipulation. The delay in diagnosis was >3 months in 75%. The clinical presentation was asymptomatic prosthetic valve dysfunction in 31%, heart failure in 19%, coronary syndrome in 12.5%, fever in 25%, and neurological deficits in 19%. At diagnosis, 62.5% had heart failure and 44% had fever. The predominant echocardiographic finding was prosthesis dysfunction due to dehiscence of metallic aortic valves (6 out of 7) or stenosis of metallic mitral valves (4 out of 7). In 2 of the 3 biological aortic prostheses, dysfunction was due to leaflet distortion. Blood cultures and surgical specimens tested positive after a mean of 11.6 and 12.2 days, respectively. In 2 cases, the diagnosis was confirmed by PCR. The principle intraoperative finding was the presence of abundant grayish pannus. Histology demonstrated the absence of acute inflammatory features. Twelve patients received antibiotic treatment with valve replacement: 7 were cured, 4 experienced early prosthesis dehiscence and 1 relapsed. All 3 patients who were initially treated with antibiotics alone suffered relapses.

CONCLUSIONS

Generally, PAPVE presents as prosthetic valve dysfunction with few symptoms of infection. Prolonged incubation of cultures is essential for diagnosis. Antibiotic treatment provides clinical control but does not eradicate the infection, and valve replacement is necessary for a cure. The postoperative course can be complicated by prosthesis dehiscence.