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PubMed1986

Prosthetic valve endocarditis. Analysis of factors affecting outcome of therapy.

We analyzed the outcome of 116 patients with prosthetic valve endocarditis treated between 1975 and 1983 and used multivariate analysis to identify risk factors for in-hospital mortality and bad outcome during follow-up. Complicated prosthetic valve endocarditis was defined as the presence of a new or changing heart murmur, new or worsening heart failure, new or progressive cardiac conduction abnormalities, or prolonged fever during therapy. Complicated prosthetic valve endocarditis was present in 64% of patients; factors associated with complicated prosthetic valve endocarditis included aortic valve infection (odds ratio 4.3, p = 0.002) and onset of endocarditis within 12 months of the cardiac operation (odds ratio 5.5, p = 0.0001). The in-hospital mortality rate for prosthetic valve endocarditis was 23%; patients with complicated prosthetic valve endocarditis had a higher mortality than patients with uncomplicated infection (odds ratio 6.4, p = 0.0009). Combined medical-surgical therapy was used in 39% of patients; surgical therapy was more common in patients with complicated prosthetic valve endocarditis (odds ratio 16, p less than 0.0001) and in patients infected with coagulase-negative staphylococci (odds ratio 3.9, p = 0.003). Survival after initially successful therapy for prosthetic valve endocarditis was adversely affected by the presence of moderate or severe congestive heart failure at hospital discharge (p = 0.03). Bad outcome during follow-up (death, relapse of prosthetic valve endocarditis, or subsequent cardiac operation related to sequelae of the original infection) was more common in the medical than the medical-surgical therapy group (p = 0.02). The difference in long-term outcome between patients treated initially with medical or with medical-surgical therapy was particularly evident in those with complicated prosthetic valve endocarditis (p = 0.008). The presence of complicated prosthetic valve endocarditis is a central variable in assessing prognosis and planning therapy; the majority of patients with complicated prosthetic valve endocarditis are best treated with medical-surgical therapy. Those who are not treated surgically during their initial hospitalization are at high risk for progressive prosthesis dysfunction and require careful follow-up.

Adult↗
PubMed2001

[Current status of endocarditis prevention].

There are currently no randomized and carefully controlled human trials to definitively prove that endocarditis prophylaxis is efficient. Furthermore, most cases of endocarditis are not attributable to a medical procedure. Thus, even with a high level of application of endocarditis prophylaxis only a minority of cases could be prevented. Endocarditis is a rare disease. On the other hand, its morbidity is increasing! In addition, infective endocarditis remains still a major medical concern because of its mortality between 5% and 76%. In addition, in up to 40% of all patients suffering from endocarditis one or more heart valves have to be replaced in the following 5 to 8 years. Without treatment endocarditis has a lethality of 100%. Therefore, there is worldwide agreement that endocarditis prophylaxis is necessary. Combining the recommendations of the German and the American Heart Association, as well as the results of the European consensus conferences, with newer insights into the pathophysiology of endocarditis the following aspects are elucidated: depending on their risk of endocarditis patients are allocated into 3 groups. In the first group there are patients with prosthetic cardiac valves, patients who suffered from previous endocarditis and patients with complex cyanotic congenital heart disease and surgically constructed shunts or conduits of the aorta and/or pulmonary circulation. In these high-risk patients the prophylactic regimen for dental, oral, respiratory tract procedures is oral amoxycillin. In genitourinary and gastrointestinal procedures ampicillin and gentamicin i.v. is recommended. In patients with mostly congenital cardiac malformations, acquired valvular dysfunction, hypertrophic obstructive cardiomyopathy and mitral valve prolapse or thickened leaflets and valvular regurgitation oral amoxycillin is recommended for all medical procedures (second group). The third group consists of patients with isolated secundum atrial defect, previous coronary bypass graft surgery, patients with cardiac pacemakers or defibrillators. In this patient cohort the individual risk of endocarditis is not higher than in the general population. Therefore, endocardits prophylaxis is not recommended.

Antibiotic Prophylaxis↗
PubMed2004

Contemporary results of mitral valve repair for infective endocarditis.

OBJECTIVES: We sought to evaluate the feasibility and immediate and late results of mitral valve repair (MVRep) for acute and healed endocarditis. BACKGROUND: Improvements in techniques of MVRep have extended its feasibility in complex lesions, but experience with endocarditis is limited. METHODS: Among 78 patients operated on for mitral endocarditis between 1990 and 1999, 63 underwent MVRep. The repair was performed for acute endocarditis in 25 patients (40%) at a median of 20 days after the onset of treatment and in 38 patients (60%) for healed endocarditis after a median of 11 months. RESULTS: Repair of the mitral valve was feasible in 63 patients (81%). This repair involved annuloplasty in 61 patients (97%), valve resection in 49 (78%), shortening or transposition of chordae in 29 (46%), suture of perforation in 18 (29%), a pericardial patch in 12 (19%), and a partial mitral homograft in 7 (11%). Associated procedures were aortic valve replacement in 11 patients, bypass grafting in 3, and tricuspid repair in 2. Early complications were two deaths (3.2%), one re-operation for severe mitral regurgitation and one re-operation for subsequent aortic endocarditis. The seven-year rate of event-free survival was 78 +/- 6% in the global series. Multivariate predictors of event-free survival were hypertension (p < 0.006) and intervention for acute endocarditis (p < 0.026). Five-year survival rates were 96 +/- 4% after MVRep for acute endocarditis and 91 +/- 5% for healed endocarditis. CONCLUSIONS: Mitral valve repair is frequently feasible and gives good results in patients with infective endocarditis. Patients operated on for acute endocarditis experience more events during follow-up than those operated on after healed endocarditis but have excellent late survival.

Acute Disease↗
PubMed2006

Surgical treatment of active infective endocarditis: a continued challenge.

OBJECTIVE: This study was undertaken to examine the outcomes of surgery for active infective endocarditis in a large cohort of patients. METHODS: Three hundred eighty-three consecutive patients underwent surgery for active infective endocarditis. The mean age was 51 +/- 16 years, and 64% were men. The infected valve was native in 266 patients and prosthetic in 117. Staphylococcus aureus was the most common microorganism. Surgery consisted of valve replacement or repair in patients with infection limited to the cusps or leaflets of the valve or radical resection of seemingly infected paravalvular tissues, and reconstruction with patches and valve replacement in patients with abscess (135 patients). The mean follow-up was 6.1 +/- 5.2 years. RESULTS: There were 45 (12%) operative and 88 (23%) late deaths. The operative mortality did not change during the period of study. Preoperative shock, prosthetic valve endocarditis, paravalvular abscess, and S aureus were independent predictors of operative mortality. Age, shock, prosthetic valve endocarditis, left ventricular ejection fraction less than 40%, and recurrent endocarditis were independent predictors of death from all causes. Survivals at 15 years were 44% +/- 5% overall, 59% +/- 5% for native valve endocarditis, and 25% +/- 7% for prosthetic valve endocarditis (P = .001). Freedom from recurrent endocarditis at 15 years was 86% +/- 3% for all patients, similar to those for native and prosthetic valve endocarditis (P = .39). Freedom from reoperation at 15 years was 70% +/- 6% for all patients, similar to those for native and prosthetic valve endocarditis (P = .55). CONCLUSIONS: Surgery for endocarditis continues to be challenging and associated with high operative mortality and morbidity. Age, shock, prosthetic valve endocarditis, impaired ventricular function, and recurrent infections adversely affect long-term survival.

Cardiac Surgical Procedures↗
PubMed1995

Adults with congenital heart disease: patient knowledge of endocarditis prophylaxis.

OBJECTIVE: To determine whether adults with congenital heart disease have adequate knowledge of infective endocarditis and endocarditis prophylaxis and to ascertain whether an educational program effectively improves patient knowledge and compliance. MATERIAL AND METHODS: We asked 102 consecutive patients to complete a 12-question survey to assess their knowledge of heart disease, infective endocarditis, and endocarditis prophylaxis. RESULTS: Of 102 patients, 100 (98%) completed the questionnaire. Sixty-eight patients knew the name of their heart disease. Fifty patients correctly defined endocarditis, but only 43 knew hygiene measures that could prevent endocarditis. Ninety-six patients knew that they needed to take "a medicine" before dental procedures, and 76 of those patients (79%) knew that an antibiotic was necessary. Patient use of cardiac medications and a history of endocarditis correlated significantly with knowledge of endocarditis. Patients who had been to the Adult Congenital Heart Disease Clinic at least once knew endocarditis prevention measures and the importance of regular dental and cardiology follow-up significantly more frequently than did first-time attendees. Despite educational counseling, however, patient recall of endocarditis and its prevention is disappointing. CONCLUSION: Many adults with congenital heart disease have inadequate knowledge of their cardiac lesion, endocarditis, and endocarditis prophylaxis. Educational efforts for adults with congenital heart disease need to be updated and reinforced regularly.

Adolescent↗
PubMed2000

[Emergency valvular replacement in infective endocarditis: hospital and long term clinical course. Analysis of 45 patients].

BACKGROUND: To define the evolution of patients with infective endocarditis who require urgent valve replacement in our environment. PATIENTS AND METHODS: We followed 45 consecutive cases of infective endocarditis that require valve replacement during their hospitalization. 32 patients had native valve infective endocarditis, 7 early prosthesis valve endocarditis and 6 late prosthesis valve endocarditis. Patients were followed for a long-term period, clinical and echocardiographycally. RESULTS: In 39 cases valve replacement was performed before ending antibiotic therapy. The main indications for surgery were refractory heart failure (24 patients) and shock (11 patients). The mortality rate was 24%: 19% in native valve infective endocarditis, 43% in early prosthetic valve endocarditis and 33% in late prosthesis valve endocarditis. The first cause of death was septic shock (46%). We followed 31 over 34 survivors for a mean time 65 (DS 49) months. We found two relapses and six deaths (1 sudden death, 2 endocarditis) and 72% of patients presented class I NYHA. We detected 17% prosthetic leaks (34% in the prosthetic valve endocarditis group). CONCLUSIONS: The need of urgent valve replacement in the context of infective endocarditis is associated with a high mortality rate, and should be considered a serious condition. Long term prognosis is, however, acceptable, although 17% of patients had prosthesis leak, specially those with prosthetic valve endocarditis.

Emergencies↗
PubMed1984

Comparison of anti-alpha-haemolysin and teichoic acid antibody tests in patients with Staphylococcus aureus endocarditis or bacteraemia.

To assess the value of serological tests in differentiating endocarditis and complicated bacteraemia due to Staphylococcus aureus from uncomplicated S. aureus bacteraemia and from nonstaphylococcal endocarditis we measured teichoic acid antibodies (TAA) (by means of a gel diffusion method) and antibodies to alpha-haemolysin (ASta) in the serum of 22 patients with S. aureus endocarditis, 42 patients with complicated S. aureus bacteraemia, 21 patients with uncomplicated S. aureus bacteraemia, 27 patients with other than S. aureus endocarditis, 17 patients with culture-negative endocarditis and 337 non-infected control patients. TAA and ASta titres were found significantly more often in staphylococcal endocarditis than in non-staphylococcal endocarditis, 59 per cent versus 4 per cent for the TAA test and 32 per cent versus 0 per cent for the ASta assay. The combined use of the two tests proved best for differentiating the two groups of endocarditis from each other, 72 per cent versus 4 per cent respectively. In the culture-negative endocarditis group there were two serologically positive patients whose anti-staphylococcal antibiotic therapy based on the serological findings was successful, supporting the clinical usefulness of staphylococcal serological tests in endocarditis of unknown bacterial aetiology. The serological tests were not useful, however, in differentiating S. aureus endocarditis from complicated or uncomplicated bacteraemia due to S. aureus without endocarditis.

Adolescent↗
PubMed1985

Clinical evaluation of a fluorescent antibody test for the serological diagnosis of streptococcal endocarditis.

Serum fluorescent streptococcal antibody tests were carried out on 71 patients with clinically suspected infective endocarditis, and a final diagnosis of endocarditis was obtained in 46 patients. A serological diagnosis of streptococcal endocarditis was obtained in 10 patients who had persistently negative blood cultures, as fluorescent streptococcal antibody titres equal to or greater than 400 were detected against at least one of four strains of streptococci used as heterologous antigens. There were no false positive fluorescent antibody results with heterologous antigens during tests on 29 patients who had either non-streptococcal endocarditis, a final diagnosis other than endocarditis, or streptococcal sepsis not associated with endocarditis. A negative result with the heterologous antibody test could not, however, exclude a diagnosis of streptococcal endocarditis as six of 11 patients with endocarditis due to Streptococcus viridans or Str bovis confirmed on blood culture had serum fluorescent antibody titres less than 400 against all the heterologous streptococcal antigens tested. Homologous fluorescent streptococcal antibody titres equal to or greater than 400, using the patient's own blood culture isolate as the antigen, were found in the serum samples of 14 of 15 patients with endocarditis caused by viridans streptococci, three patients with enterococcal endocarditis, two patients with endocarditis caused by Str pneumoniae, and one patient with Str bovis endocarditis. In contrast, all five patients who had clinically insignificant streptococcal bacteraemias had serum fluorescent homologous antibody titres of only 100 or less. These results showed that the homologous serum fluorescent streptococcal antibody test could help to decide the clinical importance of a streptococcus which is initially isolated from only one or two of a number of inoculated blood culture bottles.

Aged↗
PubMed2004

Review of 65 cases of infective endocarditis in Dunedin Public Hospital.

BACKGROUND AND AIM: Infective endocarditis remains a challenging disease to manage. The objective of this study was to evaluate the management of patients diagnosed with infective endocarditis presenting to a regional hospital. METHODS: During the years 1997 to 2002, 65 episodes of bacterial endocarditis in 62 patients (20 female, 42 male; age range from 7-89 yrs, median 68 yrs) classified as definite or possible according to the Duke criteria were reviewed retrospectively. The demographic data, predisposing factors, echocardiographic findings, culture results, complications and mortality were recorded and analysed. RESULTS: Forty-five episodes (69%) were definite endocarditis and 20 episodes (31%) were possible endocarditis. All cases had undergone transthoracic or transoesophageal echocardiograms with vegetations found in 59 (91%) episodes. There were 49 cases of native valve endocarditis, 21 (34%) of whom had either congenital or acquired valvular disease. Fifteen cases (23%) were prosthetic valve endocarditis. One case was automated implantable cardioverter defibrillator leads endocarditis. Preceding dental or surgical manipulation was observed in 7 cases (11%). Aortic valve (38/59, 64%) was the most common valve involved followed by mitral valve (21/59, 36%). Staphylococcus aureus accounted for 20 episodes (31%), Streptococcus viridans for 16 episodes (25%), Enterococcus faecalis for 5 episodes (8%), other organisms for 9 episodes (14%), and culture negative endocarditis (CNE) for 15 episodes (23%). The majority of the cases had single valve involvement (50/59, 85%); only 9 cases (15%) were double valve endocarditis. Ten cases (15%) needed urgent valve replacement. The overall in-hospital mortality rate was 20% (13/65), and at 6 months was 31% (20/65). Higher 6-month mortality was seen in patients with Staphylococcus aureus endocarditis or CNE. CONCLUSIONS: Despite major advances in diagnostic technology, improvement in antimicrobial selection and monitoring, and progress in surgical techniques, the morbidity and mortality of bacterial endocarditis remain high.

Adolescent↗
PubMed1983

Staphylococcal septicaemia and endocarditis in 80 drug addicts. Aspects on epidemiology, clinical and laboratory findings and prognosis.

During 1965-1980, 80 intravenous drug addicts with staphylococcal septicaemia with or without endocarditis were admitted to the Roslagstulls Hospital. The mean age was 28.8 (range 16-57) years. 42 were females and 38 were males. Endocarditis was diagnosed in 36 of 80 (45%) and suspected in 18 of 80 (22.5%). Septicaemia alone was found in the remaining 26 patients (32.5%). The median interval between onset of disease and institution of adequate therapy for patients without endocarditis was four days and for endocarditis cases eight days. Most patients had septic toxic symptoms. Respiratory tract symptoms were most common in patients with tricuspid valve endocarditis. Tricuspid valve engagement, manifested as pulmonary septic embolism, was present in 33 of 36 (91.7%) of the episodes of endocarditis. Among these patients, murmurs were only present in 23. Haematuria was significantly more often found in patients with endocarditis than in other groups of patients. Otherwise, laboratory data could not differentiate between patients with or without endocarditis. The outcome was lethal in five patients (6.3%): Tricuspid endocarditis (one); left-sided endocarditis (two); suspected endocarditis and retrosternal abscess (one); septicaemia (one). An unfavourable outcome was correlated to patient's delay, severe underlying diseases and/or lack of co-operation. By 1983 another 12 of the patients had died, two of them from endocarditis and one from pneumonia.

Adolescent↗
PubMed1994

Determinants of the occurrence of and survival from prosthetic valve endocarditis. Experience of the Veterans Affairs Cooperative Study on Valvular Heart Disease.

For the determination of the risk factors associated with the development of and death caused by prosthetic valve endocarditis, data were reviewed from 66 patients who were prospectively entered into the Veterans Affairs Cooperative Study on Valvular Heart Disease and in whom prosthetic valve endocarditis subsequently developed. Data were recorded at 13 medical centers between October 1977 and September 1982 in patients randomized to receive a mechanical valve (Bjork-Shiley spherical disc, n = 510 patients) or a bioprosthetic valve (Hancock porcine heterograft, n = 522 patients). The average rate of prosthetic valve endocarditis development was 0.8% per year over an average follow-up period of 7.7 years. Of the 66 patients in whom prosthetic valve endocarditis developed (5.8%), 15 cases occurred within 2 months of operation (early) and 51 occurred after operation (late). The most significant preoperative predictor of prosthetic valve endocarditis was active endocarditis at the time of operation (7.4% versus 0.9%) (p = 0.001). Early prosthetic valve endocarditis occurred more frequently in patients who underwent operation for multivalvular disease (p = 0.023). Significantly related perioperative variables were coma, prolonged mechanical ventilation, deep postoperative wound infection, postoperative jaundice, ventricular tachycardia, ventricular fibrillation, and replacement of more than one valve (p < 0.05). Multivariate predictors were hypoxia (p = 0.001), preoperative endocarditis (p = 0.003), preoperative valve lesion (p = 0.020), and resident surgeon (p = 0.05). Significant preoperative variables predictive of late prosthetic valve endocarditis were mitral stenosis and mixed mitral stenosis-regurgitation. The only multivariate predictor of late prosthetic valve endocarditis was superficial wound infection (p = 0.004). Of deaths attributable to prosthetic valve endocarditis, 41% occurred in patients treated with antibiotics alone, 48% occurred in patients treated with surgical intervention and antibiotics, and death resulted in both patients who received no treatment. No difference was found in the risk of early or late postoperative prosthetic valve endocarditis developing in patients receiving the mechanical valve versus those receiving the bioprosthetic valve.

Actuarial Analysis↗
PubMed2003

Surgical treatment of pacemaker and defibrillator lead endocarditis: the impact of electrode lead extraction on outcome.

BACKGROUND: Cardiac device (CD) endocarditis is an infrequent but potentially lethal infectious complication of permanent pacemakers or implantable cardioverter-defibrillators (ICDs), and mortality rates of 30 to 35% have been reported. Medical treatment has been suggested for the treatment of CD endocarditis, but there is increasing evidence that surgical treatment is to be preferred as the best approach to achieve eradication of the infection and reduce mortality. OBJECTIVE: To evaluate the following: (1) the clinical and echocardiographic characteristics of patients with pacemaker or ICD endocarditis, (2) the outcome of this population depending on the mode of treatment (medical vs surgical treatment), and (3) the clinical, microbiological, echocardiographic, and therapeutic variables associated with patient outcome. DESIGN: Prospective cohort study. SETTING: Tertiary referral center in Barcelona, Spain. PATIENTS: All consecutive patients with infectious endocarditis (IE) admitted to the study institution between 1990 and 2001 were prospectively evaluated by a multidisciplinary treatment team, and a definite diagnosis of CD endocarditis was established when cases met pathologic or clinical criteria according to the Duke criteria. RESULTS: A total of 31 patients, 25 men and 6 women aged 61 +/- 15 years (mean +/- SD), with pacemaker or ICD endocarditis were identified among 669 consecutive patients (4.6%) with IE. During the study period, a total of 3,768 pacemakers and 460 ICDs were implanted in the study institution. In 22 cases of pacemaker endocarditis, the pacemaker was implanted in our institution, and 9 cases were referred from other institutions (incidences of endocarditis on pacemaker and ICD implanted in our institution of 0.58% and 0.65%, respectively). Medical treatment without removal of the pacing system was initially performed on seven patients; all of them (100%) had relapses of endocarditis, and one patient died. The remaining 24 patients underwent surgical removal of the pacing system; 1 patient had one relapse, 3 patients died after surgical treatment, and the others were successfully cured with no relapses after a mean follow-up of 38 +/- 9 months. Clinical, echocardiographic, microbiological, and therapeutic variables were evaluated in association with prognosis. The only prognostic factor for failure of treatment or mortality was the absence of surgical treatment (p < 0.0001). CONCLUSIONS: Electrode lead endocarditis occurred in < 1% of pacemaker and ICD implants. Conservative treatment without explantation of all hardware failed in all patients, and surgical treatment during antibiotic therapy was effective in eradication of infection but was associated with a 12.5% mortality. The only patient characteristic associated with treatment failure or death was the absence of surgical removal of all infected hardware. Complete extraction of the pacemaker or ICD should be considered as standard therapy for most patients with CD endocarditis.

Aged↗
PubMed1985

Comparison of bioprosthetic and mechanical valve replacement for active endocarditis.

The choice between bioprosthetic or mechanical prosthetic valve replacement for active valvular endocarditis has been controversial. To establish the role of each, we reviewed the case histories of 185 patients who underwent valve replacement for active valvular endocarditis during the past 5 years. All patients had life-threatening, active bacterial endocarditis of a native or prosthetic valve. Group I (88 patients) had replacement with the Ionescu-Shiley pericardial valve and Group II (97 patients) with the St. Jude Medical valve. The male/female distribution, age range, and functional classification were the same in the two groups. Mean follow-up was approximately 20 months for both groups. Valve replacement was done because of native valve endocarditis in 76 patients in Group I and 49 patients in Group II. Of the remainder of the Group I patients, six had endocarditis of a bioprosthesis and six of a mechanical valve; of the remainder of Group II patients, 30 had endocarditis of a bioprosthesis and 18 of a mechanical valve. Early mortality was not significantly different between the two groups (14 deaths in each group). Of the 74 survivors in Group I, 15 underwent valve reoperation, 10 because of recurrent endocarditis and five because of sterile perivalvular leakage. The frequency of reoperation was significantly different (p less than 0.01) from that in Group II, in which only five patients underwent valve reoperation, four for recurrent endocarditis and one for sterile perivalvular leakage. The actuarial rate for freedom from reoperation was also significantly higher in Group II patients; 94.6% were free from reoperation at 4 years compared to 75% at 4 years in Group I patients (p less than 0.01). The actuarial survival rate, which also differed significantly between groups, was 78.7% at 4 years in Group I and 87.4% at 4 years in Group II (p less than 0.05). Patients receiving a bioprosthesis for active endocarditis had a significantly higher reoperation rate and a significantly greater incidence of recurrent endocarditis (p less than 0.01). Therefore, we prefer to use a mechanical valve for valve replacement in most patients who have active endocarditis.

Adolescent↗
PubMed2001

[Culture-negative endocarditis: etiology, diagnosis, management and therapy].

BACKGROUND: Culture-negative endocarditis is a diagnostic challenge with variable clinical presentation and protean manifestations. ETIOLOGY AND DIAGNOSIS: The two main causes why endocarditis may be culture-negative are 1. antibiotic treatment prior to obtaining blood cultures, and 2. the presence of fastidious microorganisms with limited or no capacity to grow in routine blood cultures (Table 1). If initial blood cultures remain negative for 48-72 hours, these cultures should be incubated for at least an additional 2-4 weeks. Moreover, subcultures should be plated onto chocolate agar and incubated in an atmosphere of increased CO2 environment to facilitate recovery of fastidious bacteria. Additional techniques for identification of a causative organism include serologic tests and DNA/RNA-based molecular techniques. If the patient is clinically stable, the clinician can wait until culture results from initial samples are known before deciding upon either administering an empiric antibiotic therapy or obtaining further blood cultures. Certain predisposing patient characteristics or epidemiologic exposures may be associated with particular causative microorganisms in culture-negative endocarditis. In the absence of positive blood cultures echocardiography is a crucial tool in the diagnosis and management of culture-negative endocarditis which provides the basis for the visualization of endocarditis-associated cardiac lesions. In this context, transesophageal echocardiography is associated with a significantly higher sensitivity in the detection of vegetations and perivalvular complications and is, therefore, considered the diagnostic imaging method of choice in the diagnosis of culture-negative endocarditis. The Duke criteria have been shown to have a high accuracy in the diagnosis of culture-negative endocarditis. In this context global clinical judgment demonstrated a comparable sensitivity but a lower specificity. Main differential diagnoses include diseases which can mimic the clinical endocarditis syndrome as well as the echocardiographic pattern of culture-negative endocarditis, especially 1. nonbacterial thrombotic endocarditis and 2. valvular sclerosis in the presence of systemic infection (Table 2). TREATMENT: The selection of a particular antibiotic regimen in a suspected case of culture-negative endocarditis depends on demographics (e.g., age or geographic area), epidemiologic history (e.g., animal exposures, drug-use history, alcohol abuse, homelessness) and clinical characteristics which may be suggestive of an etiologic organism.

Anti-Bacterial Agents↗
PubMed1981

The clinical implications and the pathogenetic significance of circulating immune complexes in infective endocarditis.

Circulating immune complexes were determined with the 125I-Clq binding assay and the conglutinin binding assay in a prospective, longitudinal study of 40 patients with infective endocarditis, 34 patients with endocardial defects and nonseptic fever and 25 patients with septicemia without endocarditis. Fourteen patients with uncomplicated valvular lesions constituted a control group. Upon admission, 63 percent of the patients with infective endocarditis had a positive 125I-Clq binding assay versus 9, 12 and 7 percent, respectively, of the other three groups (p less than 0.001). The incidence of positive conglutinin binding assays became significantly higher during the course of infective endocarditis (53 percent) than during the course of nonseptic fever (21 percent), but, upon admission, this difference was not significant. The high incidence of Clq-binding immune complexes among patients with infective endocarditis could be attributed mainly to those patients with the characteristic features of subacute endocarditis. The incidence of circulating immune complexes in acute endocarditis was low and did not contribute to making the clinically important distinction from septicemia without endocarditis. A rise in the 125I-Clq binding assay levels during the course of infective endocarditis correlated significantly (p less than 0.01) with failure of antibiotic treatment. With the 125I-Clq binding assay, significantly higher levels were found in patients with signs of renal involvement of cutaneous vasculitis than in patients without these extracardiac manifestations of endocarditis. These results show that the determination of circulating immune complexes has clinical implications for both the diagnosis and the management of infective endocarditis and that circulating immune complexes are probably involved in the development of glomerulonephritis and vasculitis.

Adolescent↗
PubMed1991

Profile of right-sided endocarditis: an Indian experience.

The clinical profile of right-sided infective endocarditis in India was studied from a review of records of patients with infective endocarditis admitted to this hospital. From November 1982 to November 1989, 109 patients with infective endocarditis showed vegetations on cross-sectional echocardiography confirming the diagnosis of infective endocarditis. In 19 (17.4%) patients, only the right side of the heart was involved: specifically the tricuspid valve alone in 10; tricuspid and pulmonary valves in 4; tricuspid valve and right ventricular outflow tract in 1; tricuspid valve and right ventricular free wall in 1; pulmonary valve alone in 2; and bifurcation of pulmonary trunk in 1. Eleven patients (57.9%) had underlying congenital heart disease whereas the remaining 8 patients (42.1%) did not have any underlying heart disease. The latter group, therefore, had isolated right-sided infective endocarditis. Previous illnesses leading to isolated right-sided infective endocarditis were: puerperal sepsis in 4; septic abortion in 1; staphylococcal pneumonia in 2; and epididymoorchitis in one. Eight out of 11 patients with congenital heart disease did not report any previous illness. In the remaining 3, right-sided endocarditis followed cardiac surgery in one; dental extraction without prophylaxis in one; and pulmonary balloon valvoplasty in one. All patients with isolated right-sided infective endocarditis had features of septicaemia, but a murmur of tricuspid regurgitation was audible in only 4 (50%) of them. We conclude that, unlike western reports, the pattern of right-sided infective endocarditis in India is different. No drug addict with right-sided infective endocarditis was seen; puerperal sepsis and septic abortion were the commonest causes of isolated right-sided infective endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)

Abortion, Septic↗
PubMed2004

Staphylococcus aureus bacteremia and endocarditis: the Grady Memorial Hospital experience with methicillin-sensitive S aureus and methicillin-resistant S aureus bacteremia.

BACKGROUND: Staphylococcus aureus has become the leading cause of endocarditis in most published series, and nosocomial acquisition is becoming more frequent. Previous studies involved community acquired methicillin-sensitive S aureus (MSSA), but recently, methicillin-resistant S aureus(MRSA) infection has increased. This may reflect the growing presence of this microorganism in clinical practice. Few data exist comparing the relative rates of endocarditis with MSSA and MRSA bacteremia. The purpose of this study was to compare these rates in a bacteremic population referred for diagnostic echocardiography. METHODS: Since July 1999, the demographic and clinical information of 104 consecutive patients with at least 2 blood cultures with positive results for S aureus who were referred for echocardiography to be evaluated for endocarditis at Grady Memorial Hospital (Atlanta, Ga) have been entered into a database. This database has further been restricted to patients who have undergone either a transesophageal echocardiogram or a transthoracic echocardiogram. RESULTS: Of the 104 patients with S aureus bacteremia, 53 had an infection of MSSA and 51 had an infection of MRSA. There were 33 patients (31.7%) with echocardiographically confirmed endocarditis, 23 patients (43.4%) in the MSSA group versus 10 patients (19.6%) in the MRSA group (P <.009). Community-acquired MSSA bacteremia was the cause of most of the community-acquired S aureus endocarditis (20 patients [87%] vs 3 patients [30%], P =.004), and the nosocomial-acquired MRSA bacteremia was the cause of most of the nosocomial-acquired S aureus endocarditis (3 patients [13%] vs 7 patients [70%], P =.0001). CONCLUSION: Our study confirms that S aureus bacteremia is associated with high rates of endocarditis. MSSA bacteremia is associated with higher rates of endocarditis than MRSA. Community MSSA is the cause of most of the community endocarditis, whereas nosocomial MRSA is the cause of most of the MRSA endocarditis. Patients with S aureus bacteremia should be aggressively evaluated for endocarditis.

Adult↗
PubMed2005

Risk of endocarditis among patients with prosthetic valves and Staphylococcus aureus bacteremia.

PURPOSE: Staphylococcus aureus is a common cause of bacteremia and of native valve infective endocarditis. However, the risk of endocarditis in patients with a prosthetic valve who develop S. aureus bacteremia is unclear. The aim of this study was to define the risk of prosthetic valve endocarditis in patients with S. aureus bacteremia. SUBJECTS AND METHODS: All patients with a prosthetic valve or ring who developed S. aureus bacteremia during the 94-month study period were prospectively evaluated. The modified Duke criteria were used for the diagnosis of endocarditis. Patients were followed up for 12 weeks after the initial diagnosis of S. aureus bacteremia. RESULTS: The overall rate of definite prosthetic valve endocarditis among the study patients was 26/51 (51%). The risk of endocarditis was similar in patients with late (>or=12 months after valve implantation) vs. early S. aureus bacteremia (<12 months after prosthetic valve implantation) (50% vs. 52%, P=1.0), mitral vs. aortic prostheses (62% vs. 48%, P=0.24), and mechanical vs. bioprosthetic valves (62% vs. 44%, P=0.29). The 12-week mortality was higher among patients with definite vs. possible endocarditis (62% vs. 28%, P=0.019). CONCLUSION: In this investigation, approximately half of all patients with prosthetic valves who developed S. aureus bacteremia had definite endocarditis. The risk of endocarditis was independent of the type, location, or age of the prosthetic valve. The mortality of prosthetic valve endocarditis is high. All patients with a prosthetic valve who develop S. aureus bacteremia should be aggressively screened and followed for endocarditis.

Bacteremia↗