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PubMed2000

Evaluation of the Duke criteria in 93 episodes of prosthetic valve endocarditis: could sensitivity be improved?

BACKGROUND: Since publication of the Duke criteria for diagnosing endocarditis, several articles have confirmed their sensitivity when native and prosthetic valves are considered together. OBJECTIVES: To compare the differences between the older von Reyn criteria and the Duke criteria in prosthetic valve endocarditis only, and to determine if the latter's sensitivity could be improved by adding 2 minor criteria: new-onset heart failure and presence of conduction disturbances. METHODS: We retrospectively evaluated 93 episodes of prosthetic valve endocarditis from January 1986 to January 1998 in a teaching hospital, and then analyzed the 76 surgically confirmed episodes to compare the differences between the von Reyn and Duke diagnostic criteria. RESULTS: The von Reyn criteria rejected the diagnosis in 16 of the confirmed episodes, compared with 1 diagnosis missed by the Duke criteria and 1 missed using our suggested modifications. Definite diagnosis (Duke) was established in 60 episodes, compared with a diagnosis of probable (von Reyn) in 36 episodes (P<.001). Our modifications improved the sensitivity of the Duke criteria, diagnosing 70 episodes as definite (P = .02). CONCLUSIONS: As was the case with native valve endocarditis, the Duke criteria proved to be more sensitive than the von Reyn criteria in prosthetic valve endocarditis. The addition of 2 minor criteria (new-onset heart failure and presence of conduction disturbances) could improve the diagnostic sensitivity of the Duke criteria.

Adult↗
PubMed1975

Bacterial endocarditis in children under 2 years of age.

The risk of bacterial endocarditis in infants with bacterial sepsis was assessed by review of clinical and autopsy records (1930 to 1972). There were 12 cases of bacterial endocarditis among 847 patients (1.4%) dying with bacterial sepis; a single survivor was noted during the entire period. Of the 12 autopsy patients, six had underlying congenital heart disease (CHD). Among 61 patients with bacterial sepsis associated with CHD, six acquired bacterial endocarditis (10%), whereas in 786 infants with sepsis but without underlying heart disease, only six developed bacterial endocarditis (0.8%) (P less than .01). There is a high mortality in infants with bacterial endocarditis, and an increased risk of it in infants with sepsis and CHD.

Age Factors↗
PubMedDate not supplied

Bilateral infective endocarditis.

Two patients presenting with simultaneous right- and left-sided infective endocarditis requiring surgical intervention are reported. One patient developed aortic and pulmonic valve endocarditis following dental extraction, while the second patient developed mitral and tricuspid valve endocarditis secondary to a large body burn. The bilateral semilunar valve endocarditis was treated by porcine aortic valve replacement and debridement of the pulmonic valve. The bilateral atrioventricular valve endocarditis was treated by mitral and tricuspid valve replacement with porcine valves. The frequency and clinical settings in which this condition is likely to present are discussed.

Adolescent↗
PubMed1983

Reliability of two-dimensional echocardiography in diagnosing fungal endocarditis.

Although the techniques of M-mode and two-dimensional (2D) echocardiography (echo) have been found to be useful in patients with bacterial endocarditis, the 2D findings of fungal endocarditis are not known. In this report, we present the case of a young female narcotic addict with Candida albicans endocarditis in whom we diagnosed a large vegetation by 2D echo. Decision for surgery was made solely on the basis of the 2D-echo findings. We feel that 2D-echo findings are reliable in diagnosing fungal endocarditis because, with this technique, the size, shape, mobility, and exact location of the vegetation can be better identified than by the M-mode echo. In addition, early diagnosis of fungal endocarditis helps in treating the patients with medical and surgical therapy which may result in lower mortality.

Adult↗
PubMed1998

Relative value of clinical and transesophageal echocardiographic variables for risk stratification in patients with infective endocarditis.

BACKGROUND: Infective endocarditis remains a life-threatening disease, and its optimal management is of paramount importance. Transesophageal echocardiography (TEE) is useful for the diagnosis of endocarditis-induced lesions, but the prognostic significance of the method remains controversial. HYPOTHESIS: The purpose of this study was to relate clinical and TEE characteristics to the occurrence of mortality and/or systemic embolization in a consecutive series of 45 patients with a diagnosis of infective endocarditis. METHODS: All patients underwent at least one monoplane TEE. Clinical data, episodes of embolization, and echocardiographic characteristics were prospectively recorded. Stepwise logistic discriminant analysis was performed to identify the independent variables that best predicted three binary outcomes: systemic embolization, death, and systemic embolization and/or death. RESULTS: Twelve of the 45 patients (27%) died from the endocarditis. Significant univariate predictors of death were the presence of paravalvular abscess (p = 0.025), number of vegetations (p = 0.021), Staphylococcus aureus isolated in blood cultures (p = 0.002), medical treatment alone (p < 0.002), and systemic embolism (p < 0.001). In multivariate analysis, systemic embolism (chi 2 = 29.3; p < 0.01), echocardiographic evidence of paravalvular abscess (chi 2 = 5.6; p = 0.018), Staphylococcus aureus endocarditis (chi 2 = 5.5; p = 0.016), and medical treatment alone (chi 2 = 5.11; p = 0.024) emerged as optimal predictors of death. Systemic embolization occurred in 12 patients. Independent variables predicting systemic embolization were a total length of vegetations > 14 mm (p = 0.01), greater age (p = 0.02), and medical treatment alone (p = 0.03). When two or more vegetations were observed, the total length is the sum of the individual sizes. Independent risk factors for the development of systemic emboli and/or death as a combined end point were total length of vegetations on TEE (chi 2 = 6.4; p = 0.003) and medical treatment alone (chi 2 = 4.1; p = 0.047). CONCLUSIONS: High-risk patients may be identified by the combination of clinical variables and TEE characteristics.

Discriminant Analysis↗
PubMed1992

Rheumatic manifestations of infective endocarditis.

Rheumatic manifestations are common and varied in infective endocarditis. We performed a retrospective case analysis on 87 patients with 93 episodes of infective endocarditis admitted to Flinders Medical Centre over an 11 year period (1980-1990). Disabling musculoskeletal symptoms and signs were documented in 22 (25%) of the patients. Thirteen patients developed severe or moderately severe low back pain during their illness, two with radiological evidence of a septic discitis or vertebral osteomyelitis. Two patients developed polyarthralgia/arthritis, four had septic arthritis (all with acute Staphylococcus aureus endocarditis), three developed severe loin pain, two acute gout, two had severe buttock pain and sacroiliac joint tenderness and two each developed disabling jaw/facial pain, neck/scapular pain and flank pain respectively. Five patients presented initially to the orthopaedic or rheumatological unit for management of their musculoskeletal symptoms. Four of seven patients with Streptococcus bovis endocarditis demonstrated prominent low back pain supporting a previously noted association between this organism and back symptoms. Furthermore, in one patient who had three separate episodes of endocarditis involving three different organisms, florid back symptoms were only seen in the infective episode involving Streptococcus bovis.

Aged↗
PubMed1992

Spontaneous echo contrast imaging in infective endocarditis: a predictor of complications?

Infective endocarditis is associated with significant morbidity and mortality. Valvular destruction and congestive heart failure are more common in patients with echocardiographically detectable vegetations. In addition, spontaneous platelet aggregation is increased when vegetations are present on cardiac valves. The aim of the study was to assess the prognostic value of spontaneous echo contrast (SEC) imaging, as SEC is supposed to reflect red blood cell aggregates stimulated by platelet activity. We studied 293 patients with clinical signs of infective endocarditis. Vegetations, attached to the aortic or mitral valve, were found in 130 patients (44.4%) who were followed for a mean period of 12 months. In 34 of these 130 patients (26.2%) SEC was imaged during the initial transesophageal echocardiographic examination. In these patients SEC indicated a prolonged healing of infective endocarditis with a specificity of 91.2%, a sensitivity of 77.3%, a positive accuracy of 77.3%, a negative accuracy of 74.3%. Multivariate analysis revealed that SEC is a risk factor for valve replacement (p less than 0.001) and for embolic events (p less than 0.001), less for mortality (p less than 0.01), and lowest for abscess formation (p less than 0.05). The dose of ADP to induce half-maximal platelet aggregation was significantly lower in patients with SEC (0.71 +/- 0.15 microliters) than without SEC (1.05 +/- 0.12 microliters; p less than 0.05), implying an increased spontaneous platelet aggregation in the presence of SEC. Our data provide evidence that systemically activated coagulation plays an important role in infective endocarditis. SEC, the echocardiographic implication of an increased platelet aggregation, predicts complications such as thromboembolic events and the need for surgery and is closely related to the prolonged healing period of infective endocarditis. In addition to demonstrating vegetations, transesophageal echocardiography provides information helpful in assigning patients to a high-risk subgroup. Transesophageal echocardiography may play an important role in assessing the clinical outcome of these patients.

Adult↗
PubMed1995

Outpatient treatment of endocarditis in a clinic-based program in Argentina.

The major cost in the treatment of infective endocarditis (IE) is the length of hospitalization required for the administration of intravenous antibiotics. This can be reduced by substituting shorter regimens and by the introduction of outpatient parenteral antibiotic therapy (OPAT). Careful selection of patients is vital for the success of OPAT in IE. The patients should be hemodynamically stable and without clinical complications. The delivery of OPAT for IE followed a clinical and home-based program involving an endocarditis team whose members included an infectious diseases physician, a microbiologist, a cardiologist and a nurse trained in intravenous techniques. Among the antimicrobial agents used in OPAT of IE, single-agent ceftriaxone for four weeks followed by a short course of amoxicillin or ceftriaxone in combination with an aminoglycoside for two weeks (short course) are effective modes of treatment for streptococcal endocarditis, the most common cause of IE. This treatment is also effective for carefully selected patients with other types of endocarditis, such as those due to the HACEK group (Haemophilus aphrophilus/paraphrophilis, Actinobacillus actinomycetem comitans, Caradiobacterium hominis, Eikenella corrodens and Kingella kingae). Staphylococcus aureus, enterococci and late prosthetic valve endocarditis associated with a streptococcus may also be treated on an outpatient basis after stabilization (approximately 2 weeks). As a result of their need for prolonged treatment periods, these patients are also very good candidates for OPAT. In conclusion, new regimens utilizing ceftriaxone once daily and short-term therapy on a clinical or home basis offer the potential benefits of cheaper safer and more convenient treatment for patients with IE.

Ambulatory Care Facilities↗
PubMed1995

Enterococcus faecalis colonisation and endocarditis in five intensive care patients as late sequelae of selective decontamination.

OBJECTIVE: To describe Enterococcus faecalis colonisation and endocarditis in 5 intensive care patients after treatment with selective decontamination (SDD). SETTING: Intensive care unit (ICU) in a general hospital. PATIENTS: The patients were admitted to the ICU because of adult respiratory distress syndrome, polytrauma (2 patients), abdominal aortic surgery and gastrointestinal surgery. Because these patients needed mechanical ventilation they received systemic cefotaxime and SDD (polymyxin E, amphotericin B and norfloxacin). RESULTS: Colonisation with E. faecalis was documented in all patients. Intravascular catheter-related infection with E. faecalis occurred in 4 patients. None of the patients received antibiotics active against, E. faecalis, because body temperature normalised after catheter removal. In the course of his ICU stay one patient died. Autopsy showed E. faecalis endocarditis. The other 4 patients recovered from their primary illness, but had to be readmitted after several months because of E. faecalis endocarditis. One of these patients died. One patient recovered of endocarditis, but one year later valve surgery was necessary. The other 2 patients needed acute valve replacement. The latter 3 patients survived. CONCLUSION: We observed 5 patients with E. faecalis endocarditis as a late and severe sequela of SDD during their ICU stay.

Aged↗
PubMedDate not supplied

Infective endocarditis of an interventricular patch caused by Acinetobacter haemolyticus.

A case of infective endocarditis caused by Acinetobacter haemolyticus affecting and interventricular patch is reported. The patient, a 21-year-old man with a Fallot's tetralogy who had undergone cardiovascular surgery several years before, received imipenem and gentamicin for 6 and 4 weeks respectively and showed a good response without needing surgical treatment. Endocarditis by Acinetobacter species is very unusual and, to our knowledge, this is the first reported case of infective endocarditis caused by A. haemolyticus. As the clinical characteristics and the response to antibiotics appear to be similar to those reported for infective endocarditis by Acinetobacter lwoffi, prosthetic infective endocarditis by A. haemolyticus is apparently not always an indication for surgical treatment.

Acinetobacter↗
PubMed1994

Prospective evaluation of a two-week course of intravenous antibiotics in intravenous drug addicts with infective endocarditis. Grupo de Estudio de Enfermedades Infecciosas de la Provincia de Cádiz.

In a prospective study, a two-week course of antibiotics (cloxacillin 2 g/4 h plus amikacin 7.5 mg/kg/12 h) was evaluated in the therapy of right-sided infective endocarditis in intravenous drug users (IVDU). All IVDU admitted to hospital during the study period who fulfilled the strict criteria for diagnosis of infective endocarditis were analysed. A subgroup of patients with right-sided endocarditis caused by Staphylococcus aureus who had a good prognosis were selected as being eligible for the two-week course of treatment. In a total of 139 episodes of infective endocarditis in IVDU, 72 (51.8%) cases were eligible for the two-week treatment. Of this group, 67 were cured, 4 needed prolongation of treatment to cure the infection and 1 died in hospital of respiratory distress syndrome on day 10 of treatment. In patients not eligible for the two-week treatment, the mortality was higher (24.2% versus 0.7%; p = 0.00015). Drug toxicity in the treated group was low. It can be concluded that administration of cloxacillin and amikacin parenterally for 14 consecutive days was successful in the therapy of right-sided endocarditis in IVDU.

Adult↗
PubMed2001

[Diagnosis of endocarditis today: Duke criteria or clinical judgment?].

DIAGNOSIS OF INFECTIVE ENDOCARDITIS: Due to the complexity of the clinical diagnosis of infective endocarditis, standardized diagnostic schemes have been developed to improve the sensitivity and specificity of the diagnosis. The Von Reyn criteria, introduced in 1981 relied mainly on clinical, microbiological, and histopathological criteria and were for more than 10 years regarded as the diagnostic goldstandard. However, the Von Reyn criteria have a sensitivity of merely about 30-60% and their reliability is especially low in case of negative blood cultures. ROLE OF ECHOCARDIOGRAPHY: An important step towards an improved sensitivity and specificity in the diagnosis of infective endocarditis was the introduction of transesophageal echocardiography, which is far more sensitive and specific in this indication than the transthoracic approach. Besides the early detection of vegetations and complications such as abscess formation, valvular destructions or perforations, echocardiography may be helpful to identify patients at risk for a prolonged healing, embolization, or may be also used to monitor the therapeutic progress. THE DUKE CRITERIA: Implementation of echocardiography into the Duke criteria, introduced in 1994, yielded as expected, a significant higher sensitivity of up to 100% than the von Reyn criteria with an almost identical specificity. Thus, the latter were completely replaced by the Duke criteria in clinical practice. MODIFICATIONS OF THE DUKE CRITERIA: Nevertheless, some uncertainty remains, especially in culture-negative endocarditis which has led to certain modifications of the Duke criteria. Besides the implementation of unspecific inflammatory parameters such as the C-reactive protein, a positive Q-fever serology has been added and any S. aureus bacteremia is now judged as major criterion. Although a prospective evaluation has to be awaited, these modifications appear promising and should be implemented into clinical practice. CONCLUSIONS: The Duke criteria are currently the most sensitive tool in the diagnosis of infective endocarditis. It can be expected that they will help to significantly shorten the time to diagnosis, and may, thus, improve the clinical outcome.

Diagnosis, Differential↗
PubMed2004

[Neurological complications of infective endocarditis].

Infective endocarditis involves the brain in 20-40% of cases. The neurologic syndrome often is the presenting feature. The most frequent neurologic complication is cerebral ischemia. In these patients and those with intracranial hemorrhage, a heart murmur as well as systemic signs of inflammation point to endocarditis. The encephalopathy in endocarditis is mostly due to cerebral infarction. In bacterial meningitis and brain abscess an uncommon isolate arouses suspicion. The most important therapy is antibiotic treatment. Valve replacement improves outcome; in the acute phase of endocarditis, however, it is only necessary in a third of the patients. Neurologic complications interfere with the timing of the valve replacement. If it is urgently required, its risk is reasonable within 3 days after cerebral ischemia; if possible 2-4 weeks should be waited. Cases of successful valve replacement within 4 weeks after intracranial hemorrhage have been reported, but it is recommended to postpone it for 4-6 weeks. There are no data available for the other neurologic complications. Even today patients with endocarditis challenge the diagnostic and therapeutic capacity of various disciplines.

Brain Diseases↗
PubMed2002

Knowledge, compliance and practice of antibiotic endocarditis prophylaxis of patients with congenital heart disease.

The aim of this study was to determine the knowledge, compliance, and practice of antibiotic endocarditis prophylaxis (AEP) for patients with congenital heart disease (CHD) during various diagnostic or therapeutic procedures. Patients (296) and their parents were interrogated during a visit with an 18-question survey pertaining to the practice of AEP. Most patients (91.6%) had acyanotic congenital heart disease, usually preoperative (45.3%), or had high risk of infective endocarditis due to previous endocarditis (2.0%), cyanosis (8.4%), or prosthetic valves (5.4%). Potential sources for failure of AEP were (1) no existence of a wallet card (6.8%), no communication between patient and doctor concerning the potential risk of endocarditis during a visit (13.2%), or no sufficient anamnestic inquiry by the physician before procedures were performed (43.2%). The patients underestimated (4.4%) or had no knowledge of the individual risks of endocarditis (37.5%) or underestimated indication for AEP (11.1%). AEP was often not performed at all (60.5%). Bad dental status with no previous dental therapy (35.5%) and a high rate of caries (17.2%) or gingivitis (7.4%) even in young children was frequent. AEP for patients with CHD has not been sufficiently used because of the patient's, and the physician's failure to take the necessary steps, the cardiac diagnosis, or the dental health status. Alternative strategies in prophylaxis for AEP are discussed here.

Adolescent↗
PubMed2000

Scintigraphic detection of acute experimental endocarditis with the technetium-99m labelled glycoprotein IIb/IIIa receptor antagonist DMP444.

Bacterial endocarditis is an important clinical problem that may result in persistent bacteraemia and irreversible cardiac damage. Since endocarditis is characterized by aggregation of activated platelets, fibrin and bacteria, we studied DMP444, a technetium-99m labelled high-affinity antagonist of the GP IIb/IIIa receptor that is expressed on activated platelets. In seven Beagle dogs (11-15 kg), the left ventricle was catheterized via the right carotid artery. One hour later, 5x10(7) colony forming units of Staphylococcus aureus were injected intracardially. Half an hour later, the catheter was removed. Two extra dogs underwent a complete sham procedure. One day after the intervention, five infected and the two non-infected dogs were injected with 37 MBq/kg 99mTc-DMP444 and two infected dogs with 37 MBq/kg 99mTc-IgG (used as a non-specific control agent) and imaged up to 4 h after injection. Samples were obtained for tissue counting, microbiology and histology. From 1 to 2 h post injection onward, there was clear focal accumulation of DMP444 in the aortic valve region when endocarditis was present, and this accumulation increased with time. The non-infected and the 99mTc-IgG injected dogs showed only persisting blood pool activity without any focal abnormality. At 4 h post injection, the in vivo valve-to-blood pool ratios were 1.87+/-0.18 in endocarditis, 1.01+/-0.05 in non-infected controls and 1.09+/-0.02 in 99mTc-IgG injected dogs (P<0.05). It is concluded that targeting activated platelets with the 99mTc-labelled GP IIb/IIIa antagonist DMP444 allows a final diagnosis of experimental bacterial endocarditis within 4 h owing to high, specific and fast in vivo uptake.

Acute Disease↗
PubMed2004

Mid-term results of mitral valve repair for complicated active bacterial endocarditis in high-risk patients.

Mitral valve repair in endocarditis achieves a competent valve and prevents septic embolization and acute left ventricular failure, in which operative mortality could be increased. Early and mid-term results were examined to establish whether emergency mitral valve repair offers an advantage in complicated active endocarditis. Ten patients with complicated active native valve endocarditis underwent mitral valve repair. The mean age was 45.8 +/- 18.5 years; two patients were female (20%). All patients had severe mitral regurgitation, which combined in one patient with mitral valve stenosis. New York Heart Association (NYHA) functional class was IV in all patients. The macroscopically infected tissue with vegetation in all patients was excised. Multiple techniques were required to achieve valve competence. There was one (10%) hospital death in a patient with persistent congestive heart failure, and a reoperation in another (10%) after 2 years. Mean follow-up was 32.1 +/- 12.7 months (range 1-45 months) and was complete. There were no late deaths, recurrent endocarditis, or thromboembolic events. Seven patients (77.7%) were in NYHA functional class I, and two (22.2%) were in class II. Mitral valve repair in complicated active bacterial endocarditis limited to leaflet tissues has a low operative mortality and valve-related morbidity, with promising mid-term survival in high-risk patients.

Emergency Treatment↗
PubMed1999

[Homografts for mitral valve replacement in florid endocarditis--an alternative to prosthetic replacement].

INTRODUCTION: Homografts for valve replacement are indicated in acute valve endocarditis. It is assumed that they possess anti-infective properties. Homografts are an established indication in aortic valve replacement. We present our early results with homografts for mitral valve replacement in acute endocarditis. PATIENTS AND METHODS: Between July 1996 and March 1998 we used cryopreserved homografts for mitral valve replacement in seven patients. In three cases (age 24, 42, and 34 years) the indication was an acute endocarditis with subsequent severe mitral valve insufficiency. The size of the required homograft was measured preoperatively using transesophageal echocardiography. For implantation the technique described by A. Carpentier was used; for stabilization of the mitral anulus a valvular ring (Physio) was implanted. Follow-up was done every six months including clinical and echocardiographical examinations. After the first postoperative year an Ultrafast-CT was done in addition. RESULTS: One patient had complete mitral valve replacement, in the other two cases the diseased parts of the valve were completely excised and the valve was repaired using a partial homograft. There were no perioperative deaths. In the follow-ups, up to 24 months of uneventful homograft function was documented by echocardiography; no insufficiency > degree I was seen on color Doppler echocardiography. At the last follow-up (mean follow-up 16 months, range 12 to 24 months) the average mitral valve orifice was 2.5 +/- 0.5 cm2, the mean pressure gradient 2.8 +/- 0.8 mm Hg. In Ultrafast-CT no morphological abnormalities of the mitral valves and no dilatation of the left ventricle were seen. There were no signs of a recurrence of the endocarditis in any patient during the follow-up period. CONCLUSION: Homografts for mitral valve replacement are an interesting alternative to prosthetic valve replacement, especially in younger patients. In cases with acute endocarditis, in which mechanical prosthesis should not be used, a reconstruction or repair of the mitral valve with preservation of the ventricular geometry is possible even if large parts of the mitral valve are infected.

Adult↗
PubMed2006

Endocarditis associated with antineutrophil cytoplasmic antibodies: a case report and review of the literature.

We report a case of subacute bacterial endocarditis associated with small vessel vasculitis and a strongly positive cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) test. It is important to recognize this cause of positive c-ANCA because infectious endocarditis may closely mimic the clinical manifestations of ANCA-associated vasculitides such as Wegener granulomatosis or microscopic polyangiitis. Furthermore, ANCA-associated vasculitis may result in noninfectious endocarditis, which may be confused with bacterial endocarditis. In this paper, we review reported cases of ANCA-positive bacterial endocarditis and compare them to the reported cases of ANCA-associated idiopathic vasculitis with endocardial compromise.

Antibodies, Antineutrophil Cytoplasmic↗