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PubMed2000

Long term outcome of infective endocarditis in patients who were not drug addicts: a 10 year study.

OBJECTIVE: To determine the clinical features and long term prognosis of infective endocarditis in patients who were not drug addicts. DESIGN: Prospective case series. SETTING: A university hospital that is both a referral and a primary care centre. PATIENTS: 138 consecutive cases of infective endocarditis diagnosed and treated from January 1987 to March 1997. RESULTS: Mean patient age was 44 (20) years old. 95 patients (69%) had native valve endocarditis and 43 (31%) had prosthetic valve endocarditis. Staphylococci were the causal microorganisms in 34% of cases and streptococci in 33%. Severe complications occurred in 83% of patients and 51% of patients underwent surgery during the active phase (22% was emergency surgery). Inpatient mortality was 21%. During a follow up of 56 (44) months, 10 patients (9%) needed late cardiac surgery and seven (5% of the whole series) died. Overall 10 year survival was 71%. There were no significant differences in survival depending on the type of treatment received during the hospital stay (medical or combined medical-surgical). CONCLUSIONS: A high early surgery rate is related to good long term results and does not increase in-hospital mortality. Medical treatment, however, also offers favourable long term results in cases of responsive infective endocarditis where poor prognostic factors are absent.

Adult↗
PubMed2001

Echocardiographic features of Candida species endocarditis: 12 cases and a review of published reports.

OBJECTIVE: To describe the specific echocardiographic features of Candida species endocarditis. DESIGN: Retrospective review of the case records of patients with confirmed candida endocarditis. SETTING: Cases referred to three French university centres over an eight year period were studied. DESIGN: 12 patients with confirmed Candida species endocarditis infection were identified. The transthoracic (n = 12) and transoesophageal (n = 12) echocardiographic appearances were compared with the surgical findings (n = 10). RESULTS: Large dense heterogeneous vegetations were found in 11/12 cases. A hyperechogenic heterogeneous myocardial texture, observed in seven of the 12 patients, was associated with extensive myocardial damage at surgery. While it was possible to diagnose candidal cardiac infection in all patients by transthoracic echocardiography, transoesophageal echocardiography was useful for optimal assessment of the valvar and paravalvar structures. CONCLUSIONS: In the setting of endocarditis, the detection of myocardial involvement, which is characterised by a heterogeneous myocardial texture, is an argument in favour of Candida species endocarditis and may warrant early surgical intervention.

Adult↗
PubMed2002

Infective endocarditis: determinants of long term outcome.

OBJECTIVE: To evaluate predictors of long term prognosis in infective endocarditis. DESIGN: Retrospective cohort study. SETTING: Tertiary care centre. PATIENTS: 212 consecutive patients with infective endocarditis between 1980 and 1995 MAIN OUTCOME MEASURES: Overall and cardiac mortality; event-free survival; and the following events: recurrence, need for late valve surgery, bleeding and embolic complications, cerebral dysfunction, congestive heart failure. RESULTS: During a mean follow up period of 89 months (range 1-244 months), 56% of patients died. In 180 hospital survivors, overall and cardiac mortality amounted to 45% and 24%, respectively. By multivariate analysis, early surgical treatment, infection by streptococci, age < 55 years, absence of congestive heart failure, and > 6 symptoms or signs of endocarditis during active infection were predictive of improved overall long term survival. Independent determinants of event-free survival were infection by streptococci and age < 55 years. Event-free survival was 17% at the end of follow up both in medically-surgically treated patients and in medically treated patients. CONCLUSIONS: Long term survival following infective endocarditis is 50% after 10 years and is predicted by early surgical treatment, age < 55 years, lack of congestive heart failure, and the initial presence of more symptoms of endocarditis.

Adolescent↗
PubMed2005

Vasculitis masquerading as aortic valve endocarditis.

Small vessel vasculitis and endocarditis can both present with multisystem involvement and may present a diagnostic dilemma. Renal and cardiac involvement is common in small vessel vasculitis and rarely small vessel vasculitis may cause heart block. When a patient presents with diffuse symptoms, deteriorating renal function, and heart block, endocarditis and vasculitis should be included in the differential diagnosis. The case is discussed of a man with a history of aortic valve endocarditis who presented again with similar symptoms, deteriorating renal function, and heart block. There was no evidence of aortic valve endocarditis with abscess formation. A renal biopsy confirmed small vessel vasculitis and the patient responded promptly to immunosuppressive treatment. Correct diagnosis is essential in such cases, as immunosuppression in true endocarditis can be catastrophic. In this case, with the correct diagnosis, immunosuppression proved life saving and prevented erroneous aortic valve surgery.

Acute Kidney Injury↗
PubMed1980

Chronic Q fever endocarditis.

Eight patients with chronic Q fever endocarditis were treated with tetracycline for up to 40 months. In addition, five of these patients received co-trimoxazole. Six patients had prosthetic valves. Two patients who had Q fever endocarditis on their native valves required valve replacement because of haemodynamic difficulties: in only one did the Q fever endocarditis contribute to the haemodynamic difficulty. One patient died. It is suggested that medical treatment is continued until clinically and haematologically there is no evidence of endocarditis and the Q fever phase 1 antibody titre is less than 200. No recurrence of Q fever endocarditis has been detected in three of our patients who have now stopped treatment.

Adult↗
PubMed1997

Clinical and bacteriological characteristics of infective endocarditis in the elderly.

OBJECTIVE: To determine the clinical and bacteriological features of infective endocarditis in the elderly. DESIGN: Prospective case series. SETTING: A university hospital that is both a referral and a primary care centre. PATIENTS: 114 consecutive patients treated for infective endocarditis from November 1990 to December 1993: 25 were > 70 years of age (group 1) and 89 were < 70 years old (group 2). RESULTS: Location of infective endocarditis, clinical signs, and symptoms were similar in the two groups, except for a lower occurrence of embolic episodes in the elderly (group 1:8%, group 2: 28%; P < 0.04). A higher rate of infective endocarditis on intracardiac prosthetic devices was noted in group 1 (group 1: 52%, group 2: 25%; P < 0.05). The distribution of causative micro-organisms showed a higher proportion of bacteria from the gastrointestinal tract in the elderly (group D streptococci and enterococci: 48% in group 1 v 20% in group 2) and the presumed portal of entry was more often digestive (group 1: 50%, group 2: 17%; P = 0.01). Elderly patients were less often operated on (group 1: 24%, group 2: 43%; P = 0.07) and their mortality rate was higher (group 1: 28%, group 2: 13%; P = 0.08). CONCLUSIONS: Infective endocarditis in patients over 70 often occurs in those with intracardiac prosthetic devices and is more often due to bacteria from the gastrointestinal tract. Its prognosis appears to be worse than in younger subjects.

Adult↗
PubMed1999

Staphylococcus capitis endocarditis: two cases and review of the literature.

Coagulase negative staphylococci are the principal cause of prosthetic valve endocarditis but are a rare cause of native valve infections. However, the incidence of native valve endocarditis is increasing. Staphylococcus capitis is a coagulase negative staphylococcus with the capacity to cause endocarditis on native heart valves. Two cases of native valve endocarditis caused by S capitis are presented; both in patients with aortic valve disease. The patients were cured with prolonged intravenous vancomycin and rifampicin and did not need surgery during the acute phase of the illness. Five of the six previously described cases of endocarditis caused by this organism occurred on native valves and responded to medical treatment alone.

Adult↗
PubMed1987

Role of immunoblotting in the diagnosis of culture negative and enterococcal endocarditis.

Serum samples from patients with endocarditis and septicaemia due to Enterococcus faecalis, Enterococcus faecium, Streptococcus bovis, and Streptococcus sanguis were immunoblotted against antigenic extracts from all four species. In E faecalis endocarditis there was a strong IgM response to E faecalis antigenic bands of 112, 88-90, and 45-47 Kd and a strong IgG response to 88-90 and 45-47 Kd bands. In E faecium endocarditis there was a pronounced IgG response to an E faecium band of 82-90 Kd. For S bovis endocarditis, there was a strong IgG response to several components of S bovis including bands of 66, 58, 52 and 4 Kd. For S sanguis, there was a strong IgG response to bands of 80-82, 76, 60 and 45 Kd. These patterns of antibody production were absent in patients with uncomplicated septicaemia and in controls. The delineation of these patterns enabled confirmation of the final diagnosis in seven patients initially suspected of having culture negative endocarditis.

Antibodies, Bacterial↗
PubMed1995

Immunoblotting in the diagnosis of culture negative endocarditis caused by streptococci and enterococci.

AIM: To improve the diagnosis of culture negative endocarditis by diagnosing cases due to streptococci and enterococci. METHODS: Serum samples were immunoblotted against extracts of the commonest streptococci and enterococci. They were selected from patients with a cardiac murmur, persistent pyrexia and at least three negative blood cultures. The presence of patterns of endocarditis species specific antigenic bands was measured and correlated with clinical outcome. RESULTS: Negative serology was found in 28 patients where the diagnosis of endocarditis was rejected or, if proved, staphylococcal, yeast, Gram negative, systemic lupus erythematosus, due to Q fever or Chlamydia psittaci or nonbacterial thrombotic. Positive serology was found in 27 of the 34 patients where the response to antibiotics suggested streptococcal or enterococcal infection. In 22 of these there was objective evidence of endocarditis. Positive serology was also found in three of four further patients with vegetations at necropsy. CONCLUSION: The identification of patterns of antibody response on immunoblotting can be used to make a specific diagnosis of streptococcal or enterococcal endocarditis in the absence of positive blood cultures.

Antibodies, Bacterial↗
PubMed1993

Sensitivity, specificity and predictive value of blood cultures from cattle clinically suspected of bacterial endocarditis.

This study investigated the number of blood culture-positive cattle among 215 animals clinically suspected of having bacterial endocarditis. For animals that were necropsied, the sensitivity, specificity and predictive value of the diagnosis of endocarditis were calculated on the basis of the isolation of the causative bacteria from blood. Furthermore, it was investigated whether the glutaraldehyde coagulation time, total leucocyte count, per cent neutrophil granulocytes, pulse rate and duration of disease could help to discriminate endocarditis from other diseases. Among 138 animals necropsied the sensitivity, specificity and predictive value of blood cultivation were 70.7 per cent, 93.8 per cent and 89.1 per cent, respectively. None of the other measurements could be used to discriminate between endocarditis and non-endocarditis cases.

Animals↗
PubMed1983

Antibiotic treatment of infective endocarditis.

At least 85% of patients with infective endocarditis can be cured with effective therapy. Streptococci or staphylococci cause 75% of cases of endocarditis. Patients with penicillin-sensitive viridans or nonenterococcal group D streptococcal endocarditis may be treated successfully with aqueous penicillin G alone for four weeks or with combined penicillin and streptomycin for two weeks. Enterococcal endocarditis should be treated for four to six weeks with a combination of aqueous penicillin G together with either streptomycin or gentamicin. Patients with endocarditis caused by Staphylococcus aureus should receive antimicrobial therapy for four to six weeks with a semisynthetic penicillin (nafcillin or oxacillin) or a cephalosporin such as cephalothin or cefazolin. In urgent cases where empiric antimicrobial therapy is necessary before the causative organism is identified, a combination of aqueous penicillin G, nafcillin, and gentamicin is effective therapy.

Anti-Bacterial Agents↗
PubMed2006

Effect of penicillin resistance on presentation and outcome of nonenterococcal streptococcal infective endocarditis.

BACKGROUND AND AIMS: Most cases of infective endocarditis are caused by nonenterococcal streptococci. The emergence of strains resistant to penicillin is increasingly recognized worldwide. This study sought to assess the effect of penicillin resistance on presentation and outcome of streptococcal endocarditis. METHODS: A retrospective study was conducted in a single tertiary care hospital. RESULTS: Between August 1996 and December 2004, patients infected with nonenterococcal streptococcal endocarditis and known minimal inhibitory concentrations (MICs) to penicillin were included in this study. A total of 62 cases were identified: 48 (77%) cases of the streptococcal endocarditis were caused by viridans streptococci. The most common species groups identified were Streptococcus mitis in 12 (19%) cases, Streptococcus oralis in 9 (15%) cases, Streptococcus sanguis in 7 (11%) cases and Streptococcus mutans in 7 (11%) cases. There were 36 male and 26 female patients with a median age of 46 years (range: 1-85). Twenty-two patients (35%) had peripheral embolization and 10 patients (16%) died in hospital. Twenty-eight (45%) of the 62 patients were infected with streptococcal strains of MICs > or =0.125 microg/ml to penicillin. Infection with streptococcal strains of MICs > or =0.125 microg/ml to penicillin was associated with a lower incidence of all-site embolization, but was not associated with higher mortality or increased frequency of surgery. CONCLUSIONS: High-level penicillin resistance of the streptococci responsible for endocarditis was increasingly common and medical therapy with vancomycin had a good response. Penicillin resistance was associated with a decreased risk of embolization, but was not associated with higher mortality.

Adolescent↗
PubMed1989

Pathogenic effects of monocytopenia, granulocytopenia and dexamethasone on the course of experimental Pseudomonas aeruginosa endocarditis in rabbits.

Intravegetation host inflammatory cell function may play a role in the more salutary clinical outcomes in human right- vs. left-sided endocarditis. To study this in vivo, 90 rabbits with tricuspid Pseudomonas aeruginosa endocarditis received either no therapy (controls), nitrogen mustard (HN2) to induce combined granulocytopenia + monocytopenia, etoposide (VP-16-213) to induce selective monocytopenia, or dexamethasone. Intravegetation inflammatory cell influxes were scored on a semiquantitative histopathologic scale. In VP-16-213 and dexamethasone recipients and tricuspid endocarditis controls, gradual decreases in mean intravegetation bacterial densities were observed over a 13-day infection period; in contrast, HN2 treatment was associated with a significant increase in intravegetation bacterial densities by day 13 of infection (p less than 0.001 vs. other tricuspid endocarditis groups). Histopathologically, vegetations from untreated controls and dexamethasone recipients showed granulocyte influxes during infection, while HN2 treatment resulted in predominantly granulocyte depletion within infected tricuspid vegetations; VP-16-213 caused mononuclear cell depletion at this site. This study supports the concept that the granulocyte plays a critical role in modulating spontaneous endocardial clearances of bacteria in experimental tricuspid endocarditis.

Animals↗
PubMed1976

Spectrum of echocardiographic findings in bacterial endocarditis.

Forty-seven echocardiograms were obtained in 32 patients with bacterial endocarditis. Preexistent abnormalities were found in 14 patients. In five of them thought to have bacterial endocarditis on normal valves, echocardiography showed mitral stenosis (one), bicuspid aortic valve (two), and prolapse of mitral valve (two). Definite vegetations were seen in 22 patients--on the aortic valve in seven, the mitral valve in 12, and both valves in three. Ten patients had milder changes suggestive but not diagnostic of vegetations. In 12 patients, surgery confirmed the echocardiographic findings. Fourteen had systemic embolic episodes and all had echocardiographic evidence of vegetations. Abnormalities secondary to bacterial endocarditis, other than vegetations, were common. Twenty-one patients had left ventricular volume overload. Ten had a flail posterior leaflet of the mitral valve, three of which were confirmed surgically. Eight had abnormal coarsely fluttering echoes in the left ventricular outflow tract consistent with a prolapsing aortic valve or underlying aortic vegetations; four were confirmed by surgery. Five had signs of severe aortic regurgitation of recent onset (premature mitral valve closure) and all had confirmation by surgery. Echocardiographic abnormalities persisted after successful medical treatment. We conclude that echocardiography is helpful in patients with bacterial endocarditis. It permits recognition of unsuspected preexistent lesions and the characteristic vegetations, as well as the extent and nature of valvular damage secondary to bacterial endocarditis. However, echocardiography does not differentiate between active and healed lesions.

Adult↗
PubMed1979

A collaborative study of infective endocarditis in the 1970s. Emphasis on infections in patients who have undergone cardiovascular surgery.

Twenty-six major cardiovascular centers participated in a cooperative study of all cases of infective endocarditis occurring during a single calendar year to obtain an overview of infective endocarditis. The study was designed to learn which patients appear to be at highest risk to develop this infection after palliative or reparative cardiovascular surgery. Of 278 patients developing infective endocarditis during the year at these medical centers, 63 (23%) had had previous cardiovascular surgery and 215 had not. Seventy percent of the 278 patients had recognized congenital or acquired heart disease before developing the infection. Rheumatic heart disease accounted for over half of the patients with underlying structural heart disease. A majority (55%) of the 63 patients who had been operated on before developing endocarditis had prosthetic valves inserted. Of those who did not require prosthetic valves, the majority had congenital heart disease with systemic artery-to-pulmonary artery shunts. Although these data were obtained from a selected group of patients, they confirm a significant risk of endocarditis in patients with prosthetic valves and suggest that in postoperative patients with non-valvular congenital heart disease, the highest risk appears to be in cyanotic patients with palliative pulmonary artery-to-systemic artery shunts.

Adolescent↗
PubMed1979

Imaging experimental infective endocarditis with indium-111-labeled blood cellular components.

The capability of radionuclide imaging to detect experimental aortic valve infective endocarditis was assessed with indium-111 (111In)-labeled blood cells. Sequential cardiac imaging and tissue distribution studies were obtained in 17 rabbits with infective endocarditis after administration of 111In-platelets and in five after 111In-polymorphonuclear leukocytes. Forty-eight to 72 hours after platelet administration, in vivo imaging demonstrated abnormal 111In uptake in all animals in the region of the aortic valve in an anatomically distinct pattern. Images of the excised heart showed discrete cardiac uptake conforming to the in vivo image and gross pathological examination. 111In platelet uptake in vegetations from the 17 animals averaged 240 +/- 41 times greater than that in normal myocardium and 99 +/- 15 times greater uptake in blood. In contrast, 111In-leukocyte cardiac imaging showed no abnormal aortic valve uptake 24 hours after tracer administration and the lesion myocardium activity ratio was only 5 +/- 2 (3 +/- 1 for lesion/blood activity). Four normal rabbits demonstrated neither positive 111In platelet scintigraphs nor abnormal cardiac tissue uptake. Likewise, noncellular 111In was not concentrated to any significant extent in three animals with infective endocarditis. This study demonstrates that 111In platelet, but not leukocyte cardiac imaging, is a sensitive technique for detecting experimental infective endocarditis. The imaging data conform to the cellular pathology of the infective endocarditis vegetation.

Animals↗
PubMed1987

Comparison of single and multiple doses of prophylactic antibiotics in experimental streptococcal endocarditis.

Single-doses or short-term administration of beta-lactam antibiotics alone or combined with aminoglucoside antibiotics have failed to consistently prevent experimental streptococcal endocarditis induced by high inocula of bacteria poorly susceptible to killing by these antibiotics. The optimal duration of administration of antibiotics for successful prophylaxis under these circumstances has not been established. We therefore tested, in rats with catheter-induced sterile aortic vegetations, the duration of administration of antibiotic necessary to prevent endocarditis induced by bacterial inocula 100 to 10,000 times the 90% infective dose of two tolerant viridans-group streptococci and two Streptococcus faecalis strains. Multiple-dose regimens of amoxicillin alone or of amoxicillin combined with gentamicin were studied. Against the two viridans group streptococci, successful prophylaxis was achieved with multiple doses of amoxicillin alone given over 24 to 48 hr and by the combination of amoxicillin and gentamicin given for 6 to 24 hr. Against the two S. faecalis strains, multiple-dose regimens with amoxicillin alone failed, but the combination of amoxicillin and gentamicin was successful when administered for 48 to 72 hr. Thus, after challenge with high bacterial inocula, repeated doses of a beta-lactam antibiotic alone were sufficient to prevent viridans streptococcal endocarditis, but multiple doses of a bactericidal combination (beta-lactam plus aminoglucoside), as necessary for the treatment of established endocarditis, were a prerequisite for successful prophylaxis of S. faecalis endocarditis.

Amoxicillin↗
PubMed1988

Antibiotic prophylaxis of experimental endocarditis after dental extractions.

In rats with catheter-induced sterile aortic valve vegetations we studied the efficacy of single-dose amoxicillin and single-dose erythromycin prophylaxis for the prevention of bacterial endocarditis after extractions of periodontally diseased teeth. Endocarditis after extractions occurred in 89% of control animals and was due to group G streptococci, to Staphylococcus aureus, or to both organisms. A single-dose of amoxicillin or erythromycin successfully prevented endocarditis due to these bacterial species. The analysis of the bacteremia (by culturing blood drawn 1 min after extraction on penicillinase-containing blood agar plates) indicated that amoxicillin did not influence the incidence or the magnitude of circulating group G streptococci and S. aureus, while erythromycin apparently suppressed them. However, when care was taken to eliminate blood erythromycin by a lysis-centrifugation process, the incidence and magnitude of bacteremia after erythromycin prophylaxis was similar to that in control rats. We conclude that single doses of amoxicillin and erythromycin successfully prevent experimental endocarditis after dental extractions. Since this prophylaxis was operative by mechanisms other than the prevention of the circulation of bacteria before seeding the valvular vegetations, it suggests that recommendations for prevention of bacterial endocarditis should not be aimed only at providing adequate antibiotic blood levels to suppress the bacteremia produced by the invasive procedure.

Amoxicillin↗