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PubMed1993

[Bacterial endocarditis: current bacteriological data].

The bacteria causing infective endocarditis have not changed significantly despite the diversity of potential portals of entry. Streptococci (viridans) cause 35 to 45% of cases of endocarditis. Group D streptococci of gastrointestinal origin cause about 20% of cases of endocarditis: Streptococcus bovis is the most commonly isolated species followed by the enterococcus. The beta-haemolytic streptococci of Groups A, B, C and G are rarely isolated. Seventeen to thirty per cent of endocarditis is caused by staphylococci, above all Staphylococcus aureus. These infections are mainly observed in patients with prosthetic valves or intravenous catheters and in intravenous drug addicts. With respect to gram-negative bacilli, enterobacteria are rarely responsible for endocarditis and those of the HACEK group (Haemophilus, Actinobacillus, Cardiobacterium, etc.) were isolated in 3% of cases. Q fever and Chlamydia endocarditis are rare, as are fungal infections usually due to Candida. Endocarditis with negative blood cultures is still observed in about 10% of cases.

Blood↗
PubMed1993

[Infectious endocarditis in a drug addict].

PURPOSE: To compare two groups of patients with infective endocarditis, the drug addicts and non-drug addicts. We attempted to set particularities among the various aspects that involve the patient with endocarditis, due to the concurrent chronic use of cocaine intravenously. METHODS: Twenty nine patients, group B, whose clinical diagnose was compatible with infective endocarditis, with risk factor of parenteral toxicomania by cocaine were treated at Institute "Dante Pazzanese de Cardiologia" and Hospital "Emilio Ribas" in São Paulo, from 1984 to 1990. The data obtained for etiological agents, previous cardiac pathology, affected heart structures, affected heart side and clinical-surgical evolutions of group B were compared to group A (193 patients), which was also composed of patients with endocarditis, without chronic endovenous use of cocaine antecedent. The data obtained were analysed comparatively according to the chi square with Yates correction. RESULTS: Male gender (89.7%) was predominate in group B towards group A (57.0%); (p < 0.01). Previous cardiopathy, either congenital or acquired, as antecedent proning to endocarditis, was found in 89.1% of patients in group A, significantly higher than 17.2% of patients group B (p < 0.001). Staphylococcus aureus was the most frequent agent, which accounted for endocarditis of group B in 86.4% of the cases, significantly higher when compared to 23.9% of cases of group A (p < 0.01). Streptococcus viridans was the most frequent etiological agent for endocarditis of group A (44.8%), significantly higher than group B (4.5%), (p < 0.01). In concern to the affected structures, the tricuspid valve was most affected in group B (65.5%), significantly higher than group A (4.7%) p < 0.001. The mitral valve was significantly more affected in group A (45.1%) in comparison to group B (6.9%), (p < 0.05). In group A 82 patients (42.5%) required surgical treatment and this occurred in 3 patients of group b (10.3%), (p < 0.05). No significant statistical difference was found as for the general mortality (clinical and surgical) in both groups. CONCLUSION: a) presence of previous cardiac disease was lower suggesting permanent contamination blood flow by pathologic agents, mainly of those found in the skin as S. aureus; b) right side of the heart is most frequently affected, specially the tricuspid valve even without previous damage.

Adolescent↗
PubMed1993

Value and limitations of transesophageal echocardiography in infective endocarditis.

Echocardiography has contributed considerably to the evolution in the management of patients with infective endocarditis. There is a clear hierarchy with respect to sensitivity of the different methods is superior when compared to 2-D and M-mode echocardiography in identifying both vegetations and perivalvular complications e.g. abscess formation, aneurysms, mural endocardial lesions. For patients with suspected endocarditis, in whom vegetations can not be clearly identified or in whom abscess formation is suspected with transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) with mono- or multiplane scans has become the standard diagnostic procedure. For the examination of prosthetic valves it is the method of choice. It has even been suggested that it is employed as routine measure in all patients with suspected infective endocarditis. TEE is a safe semi-invasive technique with an extremely low complication rate and high sensitivity. Its specificity depends largely on the patient group which is examined. In patients with indicative clinical symptoms the specificity and the predictive value of vegetations are high. When used as screening method to assess echodense formations at cardiac valves particularly in the elderly, in whom degenerative changes prevail, its specificity and positive predictive value of vegetation-like structures are much lower. The negative predictive value of a negative transesophageal echocardiogram remains high, however. Valve abscesses are detected rarely by transthoracic echocardiography. It is the domain of TEE to assess them particularly in the aortic and mitral valve area. For them the specificity and positive predictive value of TEE in the diagnosis of infective endocarditis is high again. Of further importance was the observation that patients with vegetations of > 10 mm were more likely to suffer embolic complications. It should be noted, however, that infective endocarditis remains a clinical diagnosis: neither is the demonstration of a vegetation already the equivalent of endocarditis, nor does missing vegetations completely rule out the possibility of it. But without doubt, the presence of vegetations, of abscess formation or a concomitant pericardial effusion add valuable information to clinical diagnosis of infective endocarditis, which still needs a "high index of suspicion".

Abscess↗
PubMed1993

Neurologic complications of infective endocarditis.

The average overall incidence of neurologic complications in patients with infective endocarditis is 30%, with the vast majority of these complications in patients with left-sided valvular disease. The incidence of central nervous system manifestations, particularly of embolic events, tends to be higher in cases of endocarditis caused by more virulent organisms, such as S. aureus and the Enterobacteriaceae. The clinical presentation is dependent on the area of the central nervous system involved. CT and MRI scanning are useful radiologic imaging techniques for the diagnosis of central nervous system complications in patients with infective endocarditis; cerebral angiography should be used in patients with suspected intracranial mycotic aneurysm. The cornerstone of management is appropriate antimicrobial therapy. Neurosurgical intervention may be required for certain patients with intracranial mycotic aneurysms that do not disappear after antimicrobial therapy or for aneurysms that enlarge or bleed. Anticoagulants should be continued in patients with prosthetic valve endocarditis who do not have evidence of intracranial hemorrhage. Anticoagulants should be avoided (unless thromboembolic events are from a site other than the vegetation) in patients with native valve endocarditis owing to the risk of hemorrhagic central nervous system complications. Case fatality rates tend to be higher in patients with neurologic complications of infective endocarditis. Earlier diagnostic and therapeutic interventions for patients with central nervous system complications of infective endocarditis will, it is hoped, improve the outcome in patients with this disorder.

Anti-Bacterial Agents↗
PubMed1993

[Transesophageal echocardiography and endocarditis].

In 49 patients (34 men and 15 women with an average age of 51 years, range 21-81 years) with a total of 51 episodes of suspected or already demonstrated endocarditis, the diagnostic and therapeutic value of transthoracic echocardiography (TTE) was compared with transoesophageal echocardiography (TEE). It was demonstrated by operation, autopsy, or the course of the condition, that endocarditis was present in 34 cases, while 17 patients did not have endocarditis. The correct diagnosis was established in 19 out 51 cases (37%) by TTE and in 44 (85%) cases by TEE (p < 0.05). The number of ambiguous investigation results fell significantly from 30 (58%) with TTE to seven with TEE. A total of 14 cases of cavity formation related to endocarditis, rupture of fistulae, or perivalvular leakage from prostheses occurred. Three (21%) of these complications were demonstrated by TTE while TEE demonstrated all 14. After examination with TEE, treatment of the patients was changed in 20 cases (39%). It is concluded that: 1) TEE can confirm or exclude the diagnosis of endocarditis with much greater certainty than TTE, 2) TEE more than halves the number of ambiguous results of investigation and 3) TEE multiplies recognition of complications of endocarditis. Even although the results from the cardiological/thoracic surgical centre cannot be transferred to the primary hospital just like that, the results of these and other investigations suggest that TEE should be carried out when TTE cannot confirm or exclude clinically suspected endocarditis with certainty.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1996

[Asymptomatic endocarditis? Are consequent histological studies useful in valve surgery?].

After aortic valve replacement for endocarditis, follow-up treatment with antibiotics is imperative. However, the question of how reliable preoperative and intraoperative diagnosis of endocarditis is in cases involving aortic defects is unclear. Of the 187 patients who underwent aortic valve replacement with or without coronary bypass surgery between June 1992 and June 1994, 150 exhibited no indications of endocarditis during preoperative and intraoperative examinations. In 17 cases (Group A) histological findings indicated acute florid endocarditis in 7 patients and chronic lymphocytic endocarditis in 10. Contrarily, histological examinations of 133 patients (Group B) revealed myxoid and/or sclerotic valve degeneration. WBC and LDH activity, examined one day preoperatively and on the first and second days postoperatively, exhibited no significant differences between the two groups, with the exception of LDH activity on the first postoperative day (Group A: 490 +/- 114, Group B: 403 +/- 132, p = 0.04). Of the clinically asymptomatic patients requiring aortic valve replacement, 11.3% exhibited acute florid endocarditis upon histologic examinations. This subgroup cannot be identified based upon routine preoperative or postoperative laboratory tests or intraoperative observation. Histological examination of the aortic valve is useful for identifying the high percentage of otherwise nonidentifiable endocarditis. Further study will be required to determine therapeutic recommendations based upon such diagnosis.

Adult↗
PubMed1998

Predictors of prognosis and risk of acute renal failure in bacterial endocarditis.

BACKGROUND: The epidemiology, criteria for diagnosis and treatment of bacterial endocarditis has changed substantially in the past 2 decades, yet little attention has been given to the changing etiologies of renal insufficiency and the predictors of renal failure or the relationship between renal failure and mortality in patients with bacterial endocarditis. OBJECTIVE: To study the risk factors for the development of acute renal failure and death among patients with definite bacterial endocarditis. SETTING: Tertiary referral university medical center. METHODS: Retrospective chart review of 204 consecutive episodes of definite bacterial endocarditis as defined by the Duke criteria. Logistic regression was used to identify clinical and biochemical predictors of death and the development of acute renal failure. RESULTS: Two hundred and four episodes of endocarditis identified in 185 patients were evaluated. The overall mortality for the group was 20%. The presence of prosthetic valve endocarditis and thrombocytopenia was associated with increased risk of death in hospital. One third of the patients developed acute renal failure (defined as a serum Cr of 2 mg/dl or above). The presence of acute renal failure increased the odds (OR) of dying by 5 (p = 0.0001). Clinical and biochemical variables at presentation that were significantly associated by univariate analysis with the risk of developing acute renal failure were: increased age, a history of hypertension, thrombocytopenia, the presence of Staphylococcus aureus, and prosthetic valve infection. Age (OR 2.9, p = 0.002) and the degree of thrombocytopenia (OR 0.2, p = 0.0001) were independently associated with an increased risk of developing acute renal failure. Patients who developed acute renal failure as a result of septic syndrome or following cardiac surgery had a higher mortality when compared to other causes of acute renal failure. CONCLUSION: Acute renal failure associated with bacterial endocarditis remains a frequent clinical problem that is often associated with a fatal outcome. Patients with increased age, and the degree of thrombocytopenia were independent risk factors for developing acute renal failure.

Acute Kidney Injury↗
PubMed1998

[Natural history and prognosis in infective endocarditis].

The natural history and prognosis of native valve infective endocarditis, prosthetic endocarditis and right sided endocarditis in drug addicts is analyzed. In native endocarditis mortality during the active phase is 12% and survival at 10 years 81%. Early prosthetic endocarditis has a worse prognosis. In late prosthetic valve endocarditis prognosis depends on the infective organism: mortality is less than 10% in estreptococcal infections and higher than 50% in staphylococcal infections. Right sided endocarditis in intravenous drug addicts has a relatively benign prognosis and seldom requires surgical treatment.

Endocarditis, Bacterial↗
PubMed1978

Experimental endocarditis in rabbits. 2. Course of untreated Streptococcus faecalis infection.

Insertion of a polyethylene catheter in the left side of the heart was used to induce sterile endocarditis in 34 rabbits. Bacterial endocarditis was established by injection of approximately 10(8) Streptococcus faecalis into the blood stream simultaneous with the removal of the catheter which had been in place for 3 days. The course of the bacterial endocarditis was examined by autopsy of rabbits sacrificed at regular intervals after the infection. The results showed that the presence of the catheter was not essential for the induction or maintenance of the infection. Growth of the bacteria took place in the preformed vegetations in the aorta, on the aortic valves and in the left ventricle. However, increases in the size of the vegetations, a high density of bacteria in the vegetations and secondary spreading were found only on the aortic valves. The extracardial manifestations of left-sided S. faecalis endocarditis included constant bacteriaemia, a high frequency of septic kidney infarcts and enlargement of the spleen. This form of experimentally provoked bacterial endocarditis in rabbits provides a good imitation of human subacute endocarditis, and would thus seem to be suitable for further study of the pathophysiology of endocarditis and evaluation of the effect of treatment with antibiotics.

Animals↗
PubMed1964

BACTERIAL ENDOCARDITIS WITH CANDIDA ALBICANS SUPERINFECTION.

Clinical and pathological features of two fatal cases of bacterial endocarditis with Candida albicans superinfection are described. One patient presented with combined Streptococcus viridans and Candida endocarditis of the aortic valve. The second patient, an addict to paregoric injected intravenously, developed Staphylococcus aureus of the tricuspid valve with eventual Candida endocarditis. The responsible organisms were identified from blood cultures during the hospital course, and by culture or tissue section of postmortem material. Candida endocarditis has emerged as a disease entity in the past 20 years. The incidence is increasing and patients with bacterial endocarditis are among those at risk. Antibiotic therapy appeared to facilitate the development of Candida endocarditis in these two cases.

Anti-Bacterial Agents↗
PubMed1979

Fate of circulating immune complexes in infective endocarditis.

To examine the role of circulating immune complexes (CIC) in infective endocarditis, we studied 64 patients with infective endocarditis for the presence of CIC by the polyethylene-glycol (PEG)-precipitation test and the Clq binding test. This study was repeated during the course of the disease in 23 patients. CIC were found in 84 per cent of patients (66 per cent with acute infective endocarditis, 89 per cent with subacute infective endocarditis) during the active phase of the disease. Higer PEG precipitates were associated with typical cutaneous signs, cryoglobulins and nonstreptococcic culture-positive infective endocarditis. Under appropriate antibiotic treatment, the PEG precipitate levels of 17 patients fell within 1 month to the normal range, with a concomitant drop in cryoglobulinemia and rheumatoid factor. Conversely, uncontrolled sepsis always (six of six) yielded a rising level of CIC. These findings support the hypothesis that CIC may be important in the pathogenesis of peripheral lesions in infective endocarditis.

Adolescent↗
PubMed1993

Pediatric infective endocarditis in the modern era.

Sixty-two cases of endocarditis occurring in children between January 1977 and February 1992 were reviewed and compared with series from the 1970s and early 1980s. Changes in risk factors, pathogens, diagnostic modalities, and outcome were determined. Complex congenital heart disease (22 cases) and unrepaired ventricular septal defect (9 cases) were the most common underlying lesions. A total of 19 children with normal anatomy had endocarditis; 6 had community-acquired infection and 13 had hospital-acquired endocarditis (11 of these 13 children had central venous catheters in place, including 7 premature infants). Echocardiograms revealed vegetations in 25 of 49 patients; 24 of these patients had positive echocardiographic findings on the first study. Echocardiographic findings were most often negative in children with complex cyanotic heart disease. Staphylococcus aureus (39%) was the most common pathogen isolated and was associated with a higher incidence of central nervous system complications (p < 0.0015) and a greater need for surgical intervention (p = 0.01) than were other pathogens. Methicillin-resistant S. aureus (eight cases) and coagulase-negative staphylococci (three cases) emerged as important pathogens but were not associated with increased morbidity or mortality rates. Fungal endocarditis (six cases) had a 67% mortality rate. Overall the mortality rate was 11%. Endocarditis remained undiagnosed in seven seriously ill patients until postmortem examination. This study indicates that, during the past decade, important changes in risk factors, pathogens, and the susceptible population have altered the presentation and management of endocarditis in children.

Adolescent↗
PubMed1976

Circulating immune complexes in infective endocarditis.

To examine further the role of immune-complex deposition in infective endocarditis, we studied 29 patients with infective endocarditis for presence of complement-containing circulating immune complexes. Ninety-seven per cent (28 of 29) had serum levels of immune complexes greater than 12 mug per milliliter. Mean levels in these patients were significantly higher than in patients with sepsis without endocarditis or in normal controls (P less than 0.05). Circulating immune-complex levels were correlated with longer duration of illness (P less than 0.025), extravalvular manifestations of endocarditis (P less than 0.025) and hypocomplementemia (P less than 0.05). Patients with right-sided endocarditis had significantly higher circulating immune-complex levels than patients with left-sided involvement (P less than 0.025). In general, levels fell to zero with successful antimicrobial or surgical therapy. This drop was concurrent with disappearance of extravalvular signs, blood cultures becoming sterile, and rise in serum complement levels. These findings support the concept that immune complexes may be important in the pathogenesis of infective endocarditis.

Anti-Bacterial Agents↗
PubMed1998

Infective endocarditis in solid organ transplant recipients.

Infective endocarditis, defined as pathologically or clinically definite by the Duke criteria, was observed in 14 transplant recipients at our institutions. In addition, we reviewed 32 previously reported cases in solid organ transplant recipients. The spectrum of organisms causing infective endocarditis was clearly different in transplant recipients than in the general population; 50% of the infections were due to Aspergillus fumigatus or Staphylococcus aureus, but only 4% were due to viridans streptococci. Fungal infections predominated early (accounting for six of 10 cases of endocarditis within 30 days of transplantation), while bacterial infections caused most cases (80%) after this time. In 80% (37) of the 46 cases in transplant recipients, there was no underlying valvular disease. Seventy-four percent (34) of the 46 cases were associated with previous hospital-acquired infection, notably venous access device and wound infections. Three patients with S. aureus endocarditis had had an episode of S. aureus bacteremia > 3 weeks prior to the diagnosis of endocarditis and had received treatment for the initial bacteremia of < 14 days' duration. The overall mortality rate was 57% (26 of 46 patients died), with 58% (15) of the 26 fatal cases not being suspected during life. Endocarditis is an underappreciated sequela of hospital-acquired infection in transplant recipients.

Adult↗
PubMed1986

Serological investigations in the diagnosis and management of infective endocarditis.

In a retrospective study of 39 patients with infective endocarditis (IE) all had elevated concentrations of C reactive protein (CRP) at presentation, patients with the acute variety having significantly higher values than patients with the subacute variety. In addition, the majority of patients with subacute bacterial endocarditis had elevated concentrations of circulating immune complexes (CICs) and rheumatoid factor (RF), both of which were absent in all but one of nine patients with acute bacterial endocarditis. Two patients with subacute and one with acute bacterial endocarditis had low values of C3 and C4. Measurement of CRP, CICs, and RF did not distinguish between patients with and without extracardiac manifestations. Sequential analysis of patients revealed that a successful response to antimicrobial treatment was indicated by a striking and rapid decline in CRP, with less striking declines in CICs, RF, and IgM. Antibiotic failure was indicated by the persistence of high concentrations of CRP and CICs. We conclude that the measurement of C reactive protein is of some value in the diagnosis and management of infective endocarditis. A normal CRP concentration excludes this diagnosis. The measurement of CRP alone appears sufficient for monitoring most cases of infective endocarditis with the sequential measurement of rheumatoid factor and circulating immune complexes adding no useful information except where the CRP remains elevated despite treatment. In this latter instance, persisting high levels of CRP and circulating immune complexes together herald an ominous course.

Acute Disease↗
PubMed1989

Neurologic complications of endocarditis: a 12-year experience.

We reviewed the neurologic complications in 113 patients with native and 62 patients with prosthetic valve endocarditis. Neurologic complications occurred with the same frequency (35.3% vs 38.7%) and distribution among the two groups. Death occurred in 20.6% of patients with neurologic complications and in 13.6% of patients without neurologic complications (p = 0.23). Staphylococcus aureus endocarditis correlated statistically with the development of neurologic complications (p less than 0.01) and death (p less than 0.01). Among 50 patients discharged from the hospital after receiving only medical treatment for native valve endocarditis, and followed for a mean period of 48 months, there was one patient with mitral valve prolapse and stroke. We conclude that (1) neurologic complications occur with the same frequency in native and prosthetic valve endocarditis, (2) S aureus endocarditis increases the risk of neurologic complications and death, (3) mortality is not significantly increased in patients with neurologic complications, and (4) an episode of treated native valve endocarditis does not increase the natural history of stroke in valvular disease.

Anticoagulants↗
PubMed1997

Infective endocarditis due to unusual or fastidious microorganisms.

Infective endocarditis due to fastidious microorganisms is commonly encountered in clinical practice. Some organisms such as fungi account for up to 15% of cases of prosthetic valve infective endocarditis, whereas organisms of the HACEK group (Haemophilus parainfluenzae, H. aphrophilus, and H. paraphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) cause 3% of community-acquired cases of infective endocarditis. Special techniques are necessary to identify these microorganisms. A history of contact with mammals or birds may suggest infection caused by Coxiella burnetii (Q fever), Brucella species, or Chlamydia psittaci. A nosocomial cluster of postsurgical infective endocarditis may be caused by Legionella species or Mycobacterium species. If risk factors that are commonly associated with fungal infections (cardiac surgical treatment, prolonged hospitalization, indwelling central venous catheters, and long-term antibiotic use) are present, fungal endocarditis is possible. Patients with endocarditis and a history of periodontal disease or dental work in whom routine blood cultures are negative might have infection due to nutritionally variant streptococci or bacteria of the HACEK group. Communication between the microbiologist and the clinician is of crucial importance for identification of these microorganisms early during the course of the infection before complications such as embolization or valvular failure occur. In this article, we review the microbiologic and clinical features of these organisms and provide recommendations for diagnosis and treatment.

Anti-Bacterial Agents↗
PubMed2006

The importance of echocardiography in physicians' support of endocarditis prophylaxis.

BACKGROUND: Guidelines advocate for antimicrobial prophylaxis for prevention of bacterial endocarditis. Our objective was to explore physicians' perspectives regarding the importance of echocardiography in the evaluation and management of endocarditis prophylaxis. METHODS: A total of 260 cardiologists and 300 family physicians practicing in Ontario, Canada, were surveyed. Our main outcome measures were physician ratings of the importance of a murmur, echocardiogram findings, echocardiogram comments, comorbid conditions, guidelines, patient insistence, and medicolegal concerns on the decision to recommend prophylaxis, as well as the degree of echocardiographically detected mitral valve abnormality required prior to recommending prophylaxis. RESULTS: The survey response rate was 62%. Echocardiographic findings were rated by 81% of physicians as the most important factor influencing the decision to provide prophylaxis. Conversely, only 27% of physicians placed similar importance on clinical findings. Family physicians relied more heavily on echocardiographic than on clinical findings when supporting endocarditis prophylaxis recommendations. On average, prophylaxis was recommended for moderate to severe regurgitation in a normal valve and mild regurgitation in a mildly abnormal structural mitral valve. Physicians who reported greater reliance on echocardiographic findings advocated for prophylaxis at lower echocardiographic thresholds than did those who reported greater reliance on murmur detection for endocarditis prophylaxis decisions. CONCLUSIONS: Physicians strongly support the use of echocardiography in endocarditis prophylaxis decision making. However, the importance of echocardiography relative to other factors varies across physician specialties. Further studies must evaluate the role of echocardiography in the assessment and management of antimicrobial endocarditis prophylaxis to assist in the development of clear clinical guidelines.

Adult↗