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Background
Infective endocarditis (IE) occur when microorganisms adhere to endocardial surface of the heart. This most commonly occurs in the setting of prior trauma or damage to the heart valve. This is why intravenous drug abusers and children with congenital heart valvular anomalies are at increased risk. Until recently, the disease was classified as acute or subacute based upon the progression of the untreated disease. However, it is now recognized that there is significant clinical and etiological overlap between the two stages of the disease. Modern classifications tend to classify the disease based upon the infecting agent, which will appropriately guide antibiotic treatment.
OUTLINE
Epidemiology Disease Associations Pathogenesis Laboratory/Radiologic/Other Diagnostic Testing Gross Appearance and Clinical Variants Prognosis Treatment Commonly Used Terms Internet Links
EPIDEMIOLOGY CHARACTERIZATION
- Temporal trends in infective endocarditis: a population-based study in Olmsted County, Minnesota.
Tleyjeh IM, Steckelberg JM, Murad HS, Anavekar NS, Ghomrawi HM, Mirzoyev Z, Moustafa SE, Hoskin TL, Mandrekar JN, Wilson WR, Baddour LM.
Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn, USA.
JAMA. 2005 Jun 22;293(24):3022-8. Abstract quote
CONTEXT: Limited data exist regarding population-based epidemiologic changes in incidence of infective endocarditis (IE).
OBJECTIVE: To evaluate temporal trends in the incidence and clinical characteristics of IE.
DESIGN, SETTING, AND PATIENTS: Population-based survey using the resources of the Rochester Epidemiology Project of Olmsted County, Minnesota. One hundred seven IE episodes occurred in 102 Olmsted County residents between 1970 and 2000. The modified Duke criteria were used to validate the diagnosis of definite or possible IE.
MAIN OUTCOME MEASURES: Incidence of IE, proportion of patients with underlying heart disease, and causative microorganisms and clinical characteristics.
RESULTS: Age- and sex-adjusted incidence of IE ranged from 5.0 to 7.0 cases per 100,000 person-years during the study period and did not change significantly over time (P = .42 for trend). Infective endocarditis caused by viridans group streptococci was the most common organism-specific subgroup, with an annual adjusted incidence of 1.7 to 3.5 cases per 100,000; in comparison, IE due to Staphylococcus aureus had an annual adjusted incidence of 1.0 to 2.2 cases per 100,000. No time trend was detected for either pathogen group (P = .63 and P = .66, respectively). An increasing temporal trend was observed in the proportions of prosthetic valve IE cases (P = .09). Among people with underlying heart disease, there was an increasing temporal trend in mitral valve prolapse (P = .04) and a decreasing trend in rheumatic heart disease (P = .08). However, the absolute numbers were small. There was no time trend in rates of valve surgery or 6-month mortality during the study period (P = .97 and P = .59, respectively).
CONCLUSIONS: In this community-based temporal trend study, we found no substantial change in the incidence of IE over the past 3 decades. Viridans group streptococci continue to outnumber S aureus as the most common causative organisms of IE in this population.
Infective endocarditis: an epidemiological review of 128 episodes.
Dyson C, Barnes RA, Harrison GA.
Department of Medical Microbiology, University Hospital of Wales, Health Park, Cardiff, UK.
J Infect 1999 Mar;38(2):87-93 Abstract quote OBJECTIVES: The objective was to determine the current epidemiology of infective endocarditis.
PATIENTS AND METHODS: All microbiologically positive episodes of infective endocarditis treated at The University Hospital of Wales over a 9-year period from March 1987 to March 1996 was reviewed. Patients originated from the catchment area of The University Hospital of Wales or were referred from other hospitals in Wales. Data extraction was from records held in the Microbiology Department and, whenever possible, from patients' casenotes. The epidemiological parameters were: (1) age and sex of patients; (2) distribution of affected sites; (3) frequency of predisposing risk factors (cardiac and extracardiac); (4) incidence of early prosthetic valve endocarditis; and (5) mortality rates.
RESULTS: There were 128 microbiologically positive episodes of endocarditis in 125 patients. The mean age of the population was 53.1 years and the aortic valve was the most frequently involved site of infection (51.6%). A presumed source of infection was identified in 20% if episodes. The commonest predisposing cardiac risk factor in native valve episodes was bicuspid aortic valve (16.7%) but there was no identifiable cardiac risk factor in a much larger proportion (37.7%) of native valve episodes. There was a low incidence (0.6%) of culture positive early prosthetic valve episodes and low mortality rates for both native and prosthetic valve endocarditis (12.3% and 24.5%) in this study. Viridans streptococci were the predominant organisms. In prosthetic valve episodes with onset after the 60th postoperative day but within one postoperative year the identity of the isolate suggested, in most cases, perioperative valve contamination.
CONCLUSIONS: The epidemiology of infective endocarditis has undergone significant change. Inability to detect clinically common predisposing lesions, and the frequent absence of any identifiable predisposing cardiac risk factor mean that initial diagnosis is often difficult and demands a high index of suspicion. There was a low incidence of culture positive early prosthetic valve episodes and there were low mortality rates for both native and prosthetic valve endocarditis; these figures suggest improvements in cardiac care. The microbiological evidence indicates that the duration of the postoperative time period used for classifying prosthetic valve endocarditis into 'early' and 'late' episodes should be extended from 60 days to 1 year.
GEOGRAPHY DENMARK
Native valve infective endocarditis in the general population: a 10-year survey of the clinical picture during the 1980s.Nissen H, Nielsen PF, Frederiksen M, Helleberg C, Nielsen JS.
Cardiology Department, Odense University Hospital, Denmark.
Eur Heart J 1992 Jul;13(7):872-7 Abstract quote In a population of 930,000 inhabitants all records of native valve infective endocarditis diagnosed in the decade 1980-89 were reviewed.
Using strict case definitions 132 clinically well-defined or post-mortem diagnosed cases were found. Included were cases referred to the local department of cardiology, as well as cases treated in non-specialized departments. Of 132 cases found 23 were only diagnosed post mortem. The male/female ratio was 71/61. The median prehospital duration of symptoms was 20 days (range 0-180 days) and the median in-hospital diagnostic delay was 5 days (range 0-54 days). Known cardiac disease was found in 42% of cases, a possible portal of entry was found in 33%, but in 36% there were no predisposing factors. Remarkably, only two patients had known rheumatic heart disease and none had a known dental focus. During the clinical course 55% experienced cardiac failure and 17% embolic episodes. In 19 patients surgery was required. Of 111 culture-positive cases streptococci were found in 61 and staphylococci in 45 cases. Echocardiography was performed in 95 cases with echocardiographic signs of endocarditis in 65 patients.
Overall mortality was 33% with a mortality in clinically diagnosed cases of 18%. Of 14 cases needing immediate surgical intervention, two died.
NETHERLANDS
Epidemiology of bacterial endocarditis in The Netherlands. I. Patient characteristics.
van der Meer JT, Thompson J, Valkenburg HA, Michel MF.
Department of Clinical Microbiology, Erasmus University, Rotterdam, The Netherlands.
Arch Intern Med 1992 Sep;152(9):1863-8 Abstract quote BACKGROUND--Studies of the epidemiology of bacterial endocarditis are usually based on a retrospective review of medical records from referral centers serving diverse patient populations. These studies are therefore likely to suffer from selection bias. We conducted a nationwide prospective epidemiologic study of endocarditis in the Netherlands.
METHODS--During a 2-year period, all cases of consecutively hospitalized patients with suspected endocarditis in the Netherlands were reported to us. While hospitalized, patients were visited for an in-person interview and a review of the medical record.
RESULTS--Of 559 episodes, 438 met the criteria for endocarditis; these included 89 episodes of prosthetic valve endocarditis and 349 episodes of native valve endocarditis. Adjusted for age- and sex-specific population figures, the incidence was 19 per million person-years. The incidence increased significantly with age, and men were more often affected than women (266 and 172 cases, respectively). Rheumatic and congenital cardiac lesions formed most of the underlying heart diseases. Mitral valve prolapse was present in only 29 patients with native valve endocarditis (8.3%). A history of intravenous drug abuse was present in 32 patients (7.3%). Viridans streptococci, staphylococci, and enterococci together constituted 86% of the isolated bacterial strains. Only 1.1% of the patients had culture-negative endocarditis. Overall case fatality was 19.7% and varied widely according to causative microorganism.
CONCLUSION--The distribution of causal microorganisms, the case fatality rate, and the incidence rate of endocarditis are age related. Therefore, a meaningful comparison of data is only possible between population-based cohorts of patients with endocarditis.
SWEEDEN
Epidemiologic aspects of infective endocarditis in an urban population. A 5-year prospective study.Hogevik H, Olaison L, Andersson R, Lindberg J, Alestig K.
Department of Infectious Diseases, Goteborg University, Sweden.
Medicine (Baltimore) 1995 Nov;74(6):324-39 Abstract quote A prospective study of the epidemiology of infective endocarditis (IE) in a well-defined urban population of 428,000 inhabitants during a 5-year period was carried out. All patients were treated in the same institution, and history, diagnostic procedures, and treatment were standardized. Of 233 consecutive suspected episodes of IE, 127 fulfilled the modified von Reyn criteria.
After patients not living in the defined area were excluded, 99 episodes in 90 patients were analyzed in the epidemiologic part of the study. Of these, 33 episodes were definite endocarditis, verified by surgery or autopsy; 35 probable; and 31 possible endocarditis episodes. Another 34 episodes were found retrospectively and are included in the incidence calculation. The crude incidence was calculated to be 6.2/100,000 inhabitants per year, which is high compared to earlier studies. Adjusted to the population of Sweden, the incidence was 5.9/100,000 inhabitants per year. The annual incidence was higher for women, 6.6/100,000, than for men, 5.8/100,000. In the oldest age-group (80-89 years) the annual incidence was 22/100,000 in the prospective study and 30/100,000 if retrospective cases were included. Contrary to almost all other studies, we did not find a male predominance among our cases. Only 7% of patients were intravenous drug abusers, and 15% had a prosthetic valve.
The most common bacteria were methicillin-susceptible Staphylococcus aureus (31%) and alpha-streptococci (28%); 12% of episodes were culture negative. The mortality from IE in the population was 1.4/100,000 inhabitants per year. A higher-than-expected incidence of IE was found, especially among older patients and women.
DISEASE ASSOCIATIONS CHARACTERIZATION BICUSPID AORTIC VALVE
Bicuspid aortic valve--A silent danger: analysis of 50 cases of infective endocarditis.Lamas CC, Eykyn SJ.
St. Thomas' Hospital, London, SE1 7EH, London, United Kingdom.
Clin Infect Dis 2000 Feb;30(2):336-41 Abstract quote We analyzed 50 cases of bicuspid aortic valve endocarditis in patients who presented to St. Thomas' Hospital from 1970 through 1998.
These represented 12.3% of the 408 cases of native valve endocarditis (NVE). All patients were male, and their mean age was 39 years. Forty-five of the 50 cases were pathologically proven; 47 were clinically definite according to the Duke criteria and 49 according to our modifications of the Duke criteria. Viridans streptococci and staphylococci accounted for 72% of cases. The prevalences of clinical features were similar to those seen in NVE: fever (temperature >/=38 degrees C, 74%) and malaise (70%), although dyspnea was more frequent (36%). There was a high incidence of serious complications (72% heart failure; 30% periannular abscesses). Surgery was required during the initial admission in 82% of cases.
Overall mortality was 14%, and surgical mortality was 9%. Few patients knew they had a "heart condition," and a bicuspid aortic valve was detected in only 35% of echocardiograms performed before surgery.
INTRAVENOUS DRUG ABUSE
Clinical features, site of involvement, bacteriologic findings, and outcome of infective endocarditis in intravenous drug users.Mathew J, Addai T, Anand A, Morrobel A, Maheshwari P, Freels S.
Department of Medicine, Cook County Hospital, Chicago, IL, USA.
Arch Intern Med 1995 Aug 7-21;155(15):1641-8 Abstract quote BACKGROUND: Intravenous drug use is an increasingly common condition predisposing to infective endocarditis. Data on infective endocarditis in intravenous drug users are limited.
OBJECTIVE: To determine the clinical features, bacteriologic findings, site of involvement, complications, and mortality associated with infective endocarditis in intravenous drug users.
METHODS: Cohort study of intravenous drug users with native valve infective endocarditis.
RESULTS: A total of 125 cases of infective endocarditis occurred in 114 patients (84 cases [67%] in men and 41 cases [32%] in women) with a mean (+/- SD) age of 37 +/- 7 years. The tricuspid valve was involved in 58 cases (46%), the mitral valve in 40 cases (32%), and the aortic valve in 24 cases (19%). The microorganisms identified included Staphylococcus in 82 cases (65.6%) and Streptococcus in 32 cases (25.6%). Twenty-three patients (18%) underwent surgery, and two (9%) of them died. One hundred two patients (82%) were treated medically, and nine (9%) of them died. Fifteen patients (63%) with aortic valve involvement vs 17 patients (17%) without aortic valve involvement underwent surgery or died without surgery (odds ratio, 8.24; 95% confidence interval, 3.1 to 21.8). Among the survivors, at least one major cardiovascular complication occurred in 79 cases (69.3%).
CONCLUSIONS: Infective endocarditis in intravenous drug users affects the right and left sides of the heart with approximately equal frequency. At present, more than 90% of cases of infective endocarditis in intravenous drug users in Chicago are caused by staphylococci or streptococci. Involvement of the aortic valve is predictive of increased morbidity and mortality in intravenous drug users with infective endocarditis. With medical treatment, and surgery when medical treatment fails, intravenous drug users with infective endocarditis have an in-hospital survival rate of 91%
PATHOGENESIS CHARACTERIZATION STAPHYLOCOCCUS AUREUS
- Staphylococcus aureus endocarditis: a consequence of medical progress.
Fowler VG Jr, Miro JM, Hoen B, Cabell CH, Abrutyn E, Rubinstein E, Corey GR, Spelman D, Bradley SF, Barsic B, Pappas PA, Anstrom KJ, Wray D, Fortes CQ, Anguera I, Athan E, Jones P, van der Meer JT, Elliott TS, Levine DP, Bayer AS; ICE Investigators.
Duke University Medical Center, Durham, NC 27710, USA.
JAMA. 2005 Jun 22;293(24):3012-21. Abstract quote
CONTEXT: The global significance of infective endocarditis (IE) caused by Staphylococcus aureus is unknown.
OBJECTIVES: To document the international emergence of health care-associated S aureus IE and methicillin-resistant S aureus (MRSA) IE and to evaluate regional variation in patients with S aureus IE.
DESIGN, SETTING, AND PARTICIPANTS: Prospective observational cohort study set in 39 medical centers in 16 countries. Participants were a population of 1779 patients with definite IE as defined by Duke criteria who were enrolled in the International Collaboration on Endocarditis-Prospective Cohort Study from June 2000 to December 2003.
MAIN OUTCOME MEASURE: In-hospital mortality.
RESULTS: S aureus was the most common pathogen among the 1779 cases of definite IE in the International Collaboration on Endocarditis Prospective-Cohort Study (558 patients, 31.4%). Health care-associated infection was the most common form of S aureus IE (218 patients, 39.1%), accounting for 25.9% (Australia/New Zealand) to 54.2% (Brazil) of cases. Most patients with health care-associated S aureus IE (131 patients, 60.1%) acquired the infection outside of the hospital. MRSA IE was more common in the United States (37.2%) and Brazil (37.5%) than in Europe/Middle East (23.7%) and Australia/New Zealand (15.5%, P<.001). Persistent bacteremia was independently associated with MRSA IE (odds ratio, 6.2; 95% confidence interval, 2.9-13.2). Patients in the United States were most likely to be hemodialysis dependent, to have diabetes, to have a presumed intravascular device source, to receive vancomycin, to be infected with MRSA, and to have persistent bacteremia (P<.001 for all comparisons).
CONCLUSIONS: S aureus is the leading cause of IE in many regions of the world. Characteristics of patients with S aureus IE vary significantly by region. Further studies are required to determine the causes of regional variation.STREPTOCOCCUS AGALACTIAE
Streptococcus agalactiae infective endocarditis: analysis of 30 cases and review of the literature, 1962-1998.Sambola A, Miro JM, Tornos MP, Almirante B, Moreno-Torrico A, Gurgui M, Martinez E, Del Rio A, Azqueta M, Marco F, Gatell JM.
Hospital Clinic-Institut d'Investigacions Biomediques August Pi i Sunyer, University of Barcelona, E-08036-Barcelona, Spain.
Clin Infect Dis 2002 Jun 15;34(12):1576-84 Abstract quote We describe 30 cases (1.7%) of community-acquired penicillin-susceptible Streptococcus agalactiae endocarditis among 1771 episodes of endocarditis diagnosed in 4 Spanish hospitals from 1975 through 1998.
Endocarditis affected a native valve (most often the mitral valve) in 25 cases (83%). Surgical valve replacement was performed for 12 patients (40%). Fourteen patients (47%) died. Mortality rates for patients with native and prosthetic valve endocarditis were 36% and 100%, respectively (P=.01). The mortality rate for native valve endocarditis decreased during the last 6 years of the study (from 61% in 1975-1992 to 8% in 1993-1998; P<.05). Additionally, 115 cases in the literature from 1962-1998 were reviewed. During 1980-1998, the percentage of patients who underwent cardiac surgery increased from 24% (in the previous period, 1962-1979) to 43% (P=.05) and the mortality rate decreased from 45% to 34% (P=NS).
S. agalactiae is an uncommon cause of endocarditis with a high mortality rate, although the prognosis of native valve endocarditis has improved in recent years, probably because of an increased use of cardiac surgery.
LABORATORY/
RADIOLOGIC/
OTHER TESTSCHARACTERIZATION RADIOLOGIC
Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990's.Schulz R, Werner GS, Fuchs JB, Andreas S, Prange H, Ruschewski W, Kreuzer H.
Department of Cardiology, Georg-August-University, Gottingen, Germany.
Eur Heart J 1996 Feb;17(2):281-8 Abstract quote Prosthetic valve endocarditis is considered to be associated with a more severe prognosis than native valve endocarditis. Among other factors, inappropriate visualization of vegetations in prosthetic valve endocarditis by transthoracic echocardiography is responsible for this observation. Since the introduction of transoesophageal echocardiography into clinical practice the diagnostic sensitivity and specificity of the detection of vegetations located on prosthetic valves have been enhanced.
Therefore we aimed to determine and compare the prognosis of prosthetic valve endocarditis and native valve endocarditis in the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104 patients were seen at our institution between 1989 and 1993. Eighty patients (77%) had native valve endocarditis and 24 (23%) had late prosthetic valve endocarditis. In the latter group two patients had recurrent infective endocarditis. Patients with prosthetic valve endocarditis were older (mean age 64 vs 54 years in native valve endocarditis; P < 0.001) and the majority was female (62% vs 38% in native valve endocarditis; P < 0.05). In prosthetic valve endocarditis, infection of a valve in the mitral position predominated (65% vs 30% in native valve endocarditis; P < 0.01), whereas in native valve endocarditis more than half the cases had isolated aortic valve endocarditis (51% vs 27% in prosthetic valve endocarditis; P < 0.01). In prosthetic valve endocarditis more cases were caused by Staphylococcus aureus (31% vs 14% in native valve endocarditis; P = 0.08), whereas in native valve endocarditis the most frequent organisms were streptococci (29% vs 19% in prosthetic valve endocarditis; P = 0.12). Differences in the clinical features of native valve endocarditis and prosthetic valve endocarditis could not be found except for a higher rate of embolism in native valve endocarditis (40% vs 19% in prosthetic valve endocarditis; P < 0.05). Vegetations could be detected by transthoracic echocardiography more frequently in native valve endocarditis (71% vs 15% in prosthetic valve endocarditis; P < 0.0001). Transoesophageal echocardiography visualized vegetations in 95% of the episodes of native valve endocarditis and in 80% of the episodes of prosthetic valve endocarditis (P = 0.09). Thus, the diagnostic gain by transoesophageal echocardiography was greatest in prosthetic valve endocarditis. Patients with native valve endocarditis had significantly larger vegetations than patients with prosthetic valve endocarditis (P < 0.05 for length, P < 0.001 for width). The median time to diagnosis was similar in native valve endocarditis and prosthetic valve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditis and in 58% of those with prosthetic valve endocarditis; the median time delay between the diagnosis of infective endocarditis and surgery tended to be shorter in prosthetic valve endocarditis than in native valve endocarditis (45 vs 60 days). The in-hospital mortality and the mortality during a follow-up of 22 +/- 10 months did not significantly differ between native valve endocarditis and prosthetic valve endocarditis (21% vs 17%; 28% vs 25%).
In summary in the era of transoesophageal echocardiography, late prosthetic valve endocarditis does not seem to carry a worse prognosis than native valve endocarditis. This can be attributed in part to the improved diagnostic accuracy achieved by transoesophageal echocardiography leading to comparable diagnostic latency periods in both patient groups. Finally, better characterization of vegetations on prosthetic valves by transoesophageal echocardiography allows early lifesaving surgery in patients with prosthetic valve endocarditis.
LABORATORY MARKERS BLOOD CULTURES
- Blood culture-negative endocarditis in a reference center: etiologic diagnosis of 348 cases.
Houpikian P, Raoult D.
Unitue des Rickettsies, Universite de la Mediterranee, Faculte de medecine, CNRS UPRES A 6020, 27 Boulevard Jean Moulin, 13385 Marseille Cedex 05, France.
Medicine (Baltimore). 2005 May;84(3):162-73. Abstract quote
To identify the current etiologies of blood culture-negative infective endocarditis and to describe the epidemiologic, clinical, laboratory, and echocardiographic characteristics associated with each etiology, as well as with unexplained cases, we tested samples from 348 patients suspected of having blood culture-negative infective endocarditis in our diagnostic center, the French National Reference Center for Rickettsial Diseases, between 1983 and 2001. Serology tests for Coxiella burnettii, Bartonella species, Chlamydia species, Legionella species, and Aspergillus species; blood culture on shell vial; and, when available, analysis of valve specimens through culture, microscopic examination, and direct PCR amplification were performed.
Physicians were asked to complete a questionnaire, which was computerized. Only cases of definite infective endocarditis, as defined by the modified Duke criteria, were included. A total of 348 cases were recorded-to our knowledge, the largest series reported to date. Of those, 167 cases (48%) were associated with C. burnetii, 99 (28%) with Bartonella species, and 5 (1%) with rare, fastidious bacterial agents of endocarditis (Tropheryma whipplei, Abiotrophia elegans, Mycoplasma hominis, Legionella pneumophila). Among 73 cases without etiology, 58 received antibiotic drugs before the blood cultures. Six cases were right-sided endocarditis and 4 occurred in patients who had a permanent pacemaker. Finally, no explanatory factor was found for 5 remaining cases (1%), despite all investigations.Q fever endocarditis affected males in 75% of cases, between 40 and 70 years of age. Ninety-one percent of patients had a previous valvulopathy, 32% were immunocompromised, and 70% had been exposed to animals.
Our study confirms the improved clinical presentation and prognosis of the disease observed during the last decades. Such an evolution could be related to earlier diagnosis due to better physician awareness and more sensitive diagnostic techniques. As for Bartonella species, B. quintana was recorded more frequently than B. henselae (53 vs 17 cases). For 18 patients with Bartonella endocarditis, the responsible species was not identified. Species determination was achieved through culture and/or PCR in 49 cases and through Western immunoblotting in 22. Comparison of B. quintana and B. henselae endocarditis revealed distinct epidemiologic patterns. The 2 cases due to T. whipplei reflect the emerging role of this agent as a cause of infective endocarditis. Because identification of the bacterium was possible only through analysis of excised valves by histologic examination, PCR, and culture on shell vial, the prevalence of the disease might be underestimated. Among patients who received antibiotic drugs before blood cultures, 4 cases (7%) were found to be associated with Streptococcus species (2 S. bovis and 2 S. mutans) through 16S rDNA gene amplification directly from the valve, which shows the usefulness of this technique in overcoming the limitations of previous antibiotic treatment. Right-sided endocarditis occurred classically in young patients (mean age, 36 yr), intravenous drug users in 50% of cases, and suffering more often from embolic complications.
Finally, 5 cases without etiology or explaining factors were all immunocompetent male patients with previous aortic valvular lesions, and 3 of the 5 presented with an aortic abscess. Further investigations should be focused on this group to identify new agents of infective endocarditis.
Are blood and valve cultures predictive for long-term outcome following surgery for infective endocarditis?Renzulli A, Carozza A, Marra C, Romano GP, Ismeno G, De Feo M, Della Corte A, Cotrufo M.
Institute of Cardiac Surgery, Second University of Naples, V. Monaldi Hospital, Via L. Bianchi, Naples, Italy.
Eur J Cardiothorac Surg 2000 Mar;17(3):228-33 Abstract quote OBJECTIVE: To evaluate whether perioperative bacteria identification in blood and/or in valve cultures can predict early and late outcome of surgery for infective endocarditis, a retrospective study was performed.
METHODS: Between January 1978 and December 1998, 232 patients, 79 (34.1%) female and 153 (65.9%) male with mean age of 44. 95+/-1.03 years (range 8-79) underwent surgery for infective endocarditis on a native (162 cases) or prosthetic (70 cases) valve. Patients were divided into three groups according to the perioperative x of microbiological tests: Group A: patients with preoperative positive blood cultures (83 cases); Group B: patients with positive valve cultures (35 cases); Group C: patients with negative blood and valve cultures (114 cases). Categorical values were compared by chi(2) analysis, whereas continuous data were compared by ANOVA and Bonferroni correction for post hoc comparisons. Analysis of late survival and complications was performed with Kaplan-Meier and Log Rank test. Late mortality, reoperation, perivalvular leak, recurrence of infection were considered as treatment failure. All data were presented as mean+/-standard error. RESULTS: Hospital mortality was 10.8% (9/83) in Group A, 8.6% (3/35) in Group B, and 14.9% (17/114) in Group C (P=0.52; not significant (NS)). Ten-year survival was 62.7+/-8% in Group A, 43.9+/-19% in Group B and 62.7+/-7% in Group C (P=0.38; NS). Ten-year freedom from reoperation was 85.2+/-6% in Group A, 37.9+/-20% in Group B and 80+/-6% in Group C (P=0.0034). Ten-year freedom from treatment failure was 56.3+/-8% in Group A, 31.6+/-16% in Group B and 55. 3+/-7% in Group C (P=0.46; NS).
CONCLUSIONS: Positive blood and tissue cultures are not predictive for hospital mortality and late treatment failure in patients with infective endocarditis. Positive valve cultures, a common finding in patients with staphylococcal endocarditis, are predictive for a higher risk of reoperation.
BLOOD CULTURE NEGATIVE
Infective endocarditis in patients with negative blood cultures: analysis of 88 cases from a one-year nationwide survey in France.Hoen B, Selton-Suty C, Lacassin F, Etienne J, Briancon S, Leport C, Canton P.
Department of Infectious and Tropical Diseases, Centre Hospitalier Universitaire de Nancy, France.
Clin Infect Dis 1995 Mar;20(3):501-6 Abstract quote Blood cultures were negative in 88 (14%) of 620 cases of infective endocarditis (IE) documented in France during a 1-year nationwide survey.
In 15 of these 88 cases, the causative microorganism was identified: seven cases of Q fever endocarditis and two cases of chlamydial endocarditis were diagnosed by serological and/or immunohistologic techniques, and a pathogen was cultured from five surgically removed valves and one arterial septic embolus. Forty-two (48%) of the 88 cases involved patients who had received antibiotics before the first blood sample was taken for culture. Mortality was lower in this group than among patients who had not previously received antibiotics (7% vs. 22%, P = .05). Comparison of blood culture-negative cases of IE with blood culture-positive cases revealed that the former tended to occur more often on prosthetic valves (32% vs. 22%, P = .16), were more often left-sided (97% vs. 83%, P = .0009), less often included extracardiac symptoms at presentation (52% vs. 63%, P = .06), and were more often surgically treated (53% vs. 34%, P = .001). Mortality was similar regardless of the results of blood culture (15% vs. 21%, P = .18).
This study showed that more than 10% of all cases of IE in France are still associated with negative blood cultures and confirmed that a search for pathogens such as Coxiella burnetii and Chlamydia species is worthwhile in this situation.
GROSS APPEARANCE/
CLINICAL VARIANTSCHARACTERIZATION GENERAL LEFT-SIDED
Complicated left-sided native valve endocarditis in adults: risk classification for mortality.Hasbun R, Vikram HR, Barakat LA, Buenconsejo J, Quagliarello VJ.
Infectious Disease Section, Tulane University School of Medicine, New Orleans, La.
JAMA 2003 Apr 16;289(15):1933-40 Abstract quote CONTEXT: Complicated left-sided native valve endocarditis causes significant morbidity and mortality in adults. Lack of valid data regarding estimation of prognosis makes management of this condition difficult.
OBJECTIVE: To derive and externally validate a prognostic classification system for adults with complicated left-sided native valve endocarditis.Design, Setting, and
PATIENTS: Retrospective observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals among 513 patients older than 16 years who experienced complicated left-sided native valve endocarditis and who were divided into derivation (n = 259) and validation (n = 254) cohorts.
MAIN OUTCOME MEASURE: All-cause mortality at 6 months after baseline.
RESULTS: In the derivation and validation cohorts, the 6-month mortality rates were 25% and 26%, respectively. Five baseline features were independently associated with 6-month mortality (comorbidity [P =.03], abnormal mental status [P =.02], moderate to severe congestive heart failure [P =.01], bacterial etiology other than viridans streptococci [P<.001 except Staphylococcus aureus, P =.004], and medical therapy without valve surgery [P =.002]) and were used to create a prognostic classification system. In the derivation cohort, patients were classified into 4 groups with increasing risk for 6-month mortality: 5%, 15%, 31%, and 59% (P<.001). In the validation cohort, a similar risk among the 4 groups was observed: 7%, 19%, 32%, and 69% (P<.001).
CONCLUSIONS: Adults with complicated left-sided native valve endocarditis can be accurately risk stratified using baseline features into 4 groups of prognostic severity. This prognostic classification system might be useful for facilitating management decisions.
VARIANTS ELDERLY
Clinical and bacteriological characteristics of infective endocarditis in the elderly.Selton-Suty C, Hoen B, Grentzinger A, Houplon P, Maignan M, Juilliere Y, Danchin N, Canton P, Cherrier F.
Department of Cardiology, CHU Brabois, Nancy, France.
Heart 1997 Mar;77(3):260-3 Abstract quote OBJECTIVE: To determine the clinical and bacteriological features of infective endocarditis in the elderly.
DESIGN: Prospective case series.
SETTING: A university hospital that is both a referral and a primary care centre.
PATIENTS: 114 consecutive patients treated for infective endocarditis from November 1990 to December 1993: 25 were > 70 years of age (group 1) and 89 were < 70 years old (group 2).
RESULTS: Location of infective endocarditis, clinical signs, and symptoms were similar in the two groups, except for a lower occurrence of embolic episodes in the elderly (group 1:8%, group 2: 28%; P < 0.04). A higher rate of infective endocarditis on intracardiac prosthetic devices was noted in group 1 (group 1: 52%, group 2: 25%; P < 0.05). The distribution of causative micro-organisms showed a higher proportion of bacteria from the gastrointestinal tract in the elderly (group D streptococci and enterococci: 48% in group 1 v 20% in group 2) and the presumed portal of entry was more often digestive (group 1: 50%, group 2: 17%; P = 0.01). Elderly patients were less often operated on (group 1: 24%, group 2: 43%; P = 0.07) and their mortality rate was higher (group 1: 28%, group 2: 13%; P = 0.08).
CONCLUSIONS: Infective endocarditis in patients over 70 often occurs in those with intracardiac prosthetic devices and is more often due to bacteria from the gastrointestinal tract. Its prognosis appears to be worse than in younger subjects.
INFECTIVE
Changing profile of infective endocarditis: results of a 1-year survey in france.Hoen B, Alla F, Selton-Suty C, Beguinot I, Bouvet A, Briancon S, Casalta JP, Danchin N, Delahaye F, Etienne J, Le Moing V, Leport C, Mainardi JL, Ruimy R, Vandenesch F.
Service de Maladies Infectieuses et Tropicales, University of Besancon Medical Center, F-25030 Besancon Cedex, France.
JAMA 2002 Jul 3;288(1):75-81 Abstract quote CONTEXT: Since the first modern clinical description of infective endocarditis (IE) at the end of the 19th century, the profile of the disease has evolved continuously, as highlighted in epidemiological studies including a French survey performed in 1991.
OBJECTIVE: To update information gained from the 1991 study on the epidemiology of IE in France.
DESIGN AND SETTING: Population-based survey conducted from January through December 1999 in all hospitals in 6 French regions representing 26% of the population (16 million inhabitants).
PATIENTS: Three hundred ninety adult inpatients diagnosed with IE according to Duke criteria.
MAIN OUTCOME MEASURES: Incidence of IE; proportion of patients with underlying heart disease; clinical characteristics; causative microorganisms; surgical and mortality outcomes.
RESULTS: The annual age- and sex-standardized incidence was 31 (95% confidence interval [CI], 28-35) cases per million, not including the region of New Caledonia, which had 161 (95% CI, 117-216) cases per million. There was no previously known heart disease in 47% of the cases. The proportion of prosthetic-valve IE was 16%. Causative microorganisms were: streptococci, 48% (group D streptococci, 25%; oral streptococci, 17%, pyogenic streptococci, 6%); enterococci, 8%; Abiotrophia species, 2%; staphylococci, 29%; and other or multiple pathogens, 8%. Blood cultures were negative in 9% and no microorganism was identified in 5% of the cases. Early valve surgery was performed in 49% of the patients. In-hospital mortality was 16%. Compared with 1991, this study showed a decreased incidence of IE in patients with previously known underlying heart disease (20.6 cases per million vs 15.1 cases per million; P<.001); a smaller incidence of oral streptococcal IE (7.8 cases per million vs 5.1 cases per million; P<.001), compensated by a larger proportion of IE due to group D streptococci (5.3 cases per million vs 6.2 cases per million; P =.67) and staphylococci (4.9 cases per million vs 5.7 cases per million; P =.97); an increased rate of early valve surgery (31.2% vs 49.7%; P<.001); and a decreased in-hospital mortality rate (21.6% vs 16.6%; P =.08).
CONCLUSION: Although the incidence of IE has not changed, important changes in disease characteristics, treatment, and outcomes were noted.
PEDIATRIC
Infective endocarditis in children--incidence, pattern, diagnosis and management in a developing country.Sadiq M, Nazir M, Sheikh SA.
Department of Paediatric Cardiology, Punjab Institute of Cardiology, Lahore, Pakistan.
Int J Cardiol 2001 Apr;78(2):175-82 Abstract quote BACKGROUND: In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high. Objective: Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome. Setting: A tertiary referral center for paediatric and adult cardiology.
PATIENTS AND METHODS: All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Duke's criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases.
RESULTS: Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9 +/- 4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients).
CONCLUSIONS: The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.
Changing Risk Factors for Pediatric Infective Endocarditis.Fisher MC.
Department of Pediatrics, Monmouth Medical Center, 300 Second Avenue, Long Branch, NJ 07740, USA.
Curr Infect Dis Rep 2001 Aug;3(4):333-336 Abstract quote Infective endocarditis in children is an uncommon infection. Three major groups of children are at risk: 1) those with underlying congenital heart disease, 2) those with central vascular catheters, and 3) children infected with certain virulent organisms. Although the overall incidence of infective endocarditis has increased, the population of children involved has changed.
Children with corrected congenital heart disease are at risk during the early postoperative period. Children in whom vascular shunts or grafts are employed remain at the highest risk for endocarditis. Use of central vascular catheters increases risk in children with underlying heart disease and those with normal hearts. Finally, certain pathogens attack the heart valves and cause high morbidity and mortality.
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