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PubMed2004

A comparison of HIV-positive patients with and without infective endocarditis: an echocardiographic study--the Emory Endocarditis Group experience.

OBJECTIVE: To determine the clinical features in HIV-positive patients with and without infective endocarditis (IE). PATIENTS AND METHODS: All bacteremic, HIV-positive patients with suspected IE admitted over a four-year period who underwent either transesophageal echocardiography (TEE) or transthoracic echocardiography (TTE) were retrospectively reviewed with regard to clinical, laboratory, and demographic characteristics. RESULTS: Ten (11.5%) of 87 HIV-positive patients had a clinical diagnosis of IE based on the Duke Criteria. The mean age of patients with IE was 37.8 years and without IE 39.9 years (P = NS). Both patient groups were similar with respect to gender, race, IVDA, renal failure requiring hemodialysis, history of predisposing heart disease, origin of infection, and causative organism of infection. The mean CD4 count (cells/microL) was 200.7 in patients with IE and 95.9 in patients without IE (P = NS). Of 10 HIV-positive patients with IE, seven had left-sided heart involvement, two had complications related to IE, three required cardiothoracic surgery, and three died. CONCLUSIONS: There were no differences found with regard to the clinical characteristics of HIV-positive patients with and without IE. No correlation could be drawn between mortality and the degree of immunosuppression in patients from this study. The high incidence of IE (11.5%) and mortality rate (30%) in this study suggests that IE in HIV-positive patients, including non-intravenous drug abusers, represents a real concern for clinicians and their management of these patients.

AIDS-Related Opportunistic Infections↗
PubMed2006

Successful treatment of polymicrobial multivalve infective endocarditis. Multivalve infective endocarditis.

A 57-year-old man presented with triple valve infective endocarditis. There were vegetations on the tricuspid, mitral, and aortic valve. He had multiple complications such as pulmonary abscess, severe anaemia, and congestive heart failure. His general condition was extremely poor. Intensive medical therapy, such as blood transfusion, mechanical ventilation, and inotropic support, allowed him to tolerate surgery. Triple valve replacement was successfully performed without major complication. Vegetation cultures grew Streptococcus bovis and Enterecoccus faecalis. At 1 year follow-up, the patient is alive in NYHA functional class I.

Anemia↗
PubMed1995

Perivalvular cavities in endocarditis: abscesses versus pseudoaneurysms? A transesophageal Doppler echocardiographic study in 118 patients with endocarditis.

The appearance of perivalvular cavities (PCs) in patients with infectious endocarditis (IE) was studied by transesophageal echocardiography (TEE) color Doppler examinations to determine whether the color Doppler TEE presentation was in keeping with the current concept of PCs representing abscesses. Two heart centers participated in the study. Videotape recordings of TEE examinations in patients with IE were analyzed retrospectively for 18 months in both centers, and one center included patients prospectively for an additional 18 months. A total of 118 patients with a diagnosis of IE based on TEE and clinical and laboratory findings were seen during the study period. TEE showed PCs in 34 patients. In 3 patients who died, no autopsy was performed; the PCs were proved at autopsy or surgery in the remaining 31 patients, who constituted the study population. All PCs were echo free at TEE. Apart from one technically inadequate examination, all PCs contained color Doppler signals indicating intracavitary blood flow; the PCs communicated through a narrow channel with high-pressure regions (the left ventricle or the ascending aorta). At surgery or autopsy, only 2 of the 31 patients had pus accumulations besides the blood-filled PCs. At TEE the pus accumulations presented as echo-rich, shaggy tissue thickening. It is concluded that well-delineated, echo-free PCs with intracavitary color Doppler signals at TEE appear to be pseudoaneurysms, and therefore the term abscess should not be used in these cases. Although further studies are needed, our findings suggest that PCs more likely occur by infectious tissue weakening and subsequent dissection rather than as a result of primary abscess formation with secondary rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

Abscess↗
PubMed2006

Epidemiologic, clinical, and microbiologic profile of infective endocarditis in Argentina: a national survey. The Endocarditis Infecciosa en la República Argentina-2 (EIRA-2) Study.

BACKGROUND: This study aimed to determine the epidemiologic, clinical, microbiologic characteristics, and inhospital outcome of infective endocarditis (IE) in Argentina and compare the results with those of the 1992 IE national survey. METHODS: A prospective, multicenter study was conducted in 82 hospitals representing 16 of 24 provinces of Argentina. Patients with diagnosis of IE according to the Duke criteria were surveyed during an 18-month period. RESULTS: From 470 surveyed episodes of IE, 390 cases were classified as definite and 80 as possible IE. The mean age of the definite IE cases was 58.5 +/- 17.3 years; male sex, 70.0%; and male-female ratio, 2.3:1. Pathological evidence of IE was available in 26.2%. There was no previously known heart disease in 35.1%, and the proportion of prosthetic valve IE was 15.9%. Causative microorganisms were streptococci, 38.3% (Streptococcus viridans 27.0%, Streptococcus bovis 5.2%, others 6.1%); enterococci, 10.2%; staphylococci, 36.7% (Staphylococcus aureus 29.8%, coagulase-negative staphylococci 6.9%); HACEK group, 6.1%; fungal, 1.4%; and polymicrobial, 2.0%. Blood culture results were negative in 10.8%. Surgical treatment was performed in 26.2%, and the overall inhospital mortality was 24.6%. Patients from the 2002 survey were older (58.5 +/- 17.3 vs 51.3 +/- 18.7 years, P < .01) and more frequently had underlying heart disease (64.9% vs 55.0%, P < .01): degenerative valve disease (11.5% vs 4.8%, P < .01), congenital heart disease (9.5% vs 4.2%, P < .01), and prosthetic valve IE (15.9% vs 8.5%, P < .01). Conversely, the prevalence of rheumatic valve disease was significantly less than in the 1992 survey (5.4% vs 13.0%, P < .01). CONCLUSIONS: The EIRA-2 survey shows that the clinical profile of IE has changed in Argentina. Currently, patients with IE are older and have a higher frequency of underlying heart disease, degenerative valve disease, and prosthetic valve IE than previously. The incidence of staphylococcal IE has increased. Inhospital mortality remains high, suggesting that more aggressive measures are needed for the early identification, prevention, and treatment of IE.

Adult↗
PubMed2003

Progress toward a global understanding of infective endocarditis. Lessons from the International Collaboration on Endocarditis.

In the century and a quarter since William Osler delivered his famed Gulstonian lectures on endocarditis, continual advancements have been made in understanding and treating this disease. Here we have reviewed some key aspects of current knowledge in the areas of population epidemiology, host factors, microorganisms, and diagnosis. The advent of the ICE investigation provides the opportunity to further expand our understanding of IE by developing a very large, global database of IE patients whose clinical, echocardiographic, and microbiologic findings have been characterized with standard methodology. Further, ICE may serve as a rich source of material for investigators seeking to perform specific studies. Finally, the ICE infrastructure creates the opportunity for performing randomized trials to test therapeutic strategies. Although many obstacles remain to be overcome, ICE has created the opportunity for a quantum leap in our knowledge of IE over the next 25 years.

Comprehension↗
PubMed2004

Endocarditis in patients with a permanent pacemaker: a 1-year epidemiological survey on infective endocarditis due to valvular and/or pacemaker infection.

To describe characteristics of infective endocarditis (IE) in pacemaker (PM) recipients, including the annual incidence and exact localization of IE on PM leads, cardiac valves, or both, we prospectively analyzed 45 PM recipients from a group of 559 patients with definite IE who responded to a population-based survey conducted in France in 1999. Thirty-three patients had definite PM-lead IE (group I), and 12 had valvular IE without evidence of PM involvement (group II). The valvular structure was involved in almost two-thirds of IE cases among PM recipients. Of the 28 patients (62%) with valvular IE, 10 group I patients had tricuspid involvement, and 6 group I patients had left heart-valve involvement. The most frequent causative organisms in groups I and II were staphylococci (82%) and streptococci (50%), respectively. The incidence of age- and sex-standardized IE was 550 cases/million PM recipients per year. The incidence of IE with PM involvement is between that of valvular IE in the general population and prosthetic valve IE.

Aged↗
PubMed2000

Streptococcus pneumoniae endocarditis in adults. A multicenter study in France in the era of penicillin resistance (1991-1998). The Pneumococcal Endocarditis Study Group.

To better define the overall characteristics and risk factors for dying of adult pneumococcal endocarditis (PE) focusing on the echocardiographic diagnosis, the impact of surgery, and emergence of penicillin resistance, the medical and microbiologic charts of adult PE cases observed between 1991 and 1998 in university and general hospitals were reviewed through a nationwide retrospective study in France. Thirty cases of PE (22 men, 8 women; median age, 53 yr; range, 27-87 yr) were collected and validated. Twenty patients (66.7%) had no known predisposing cardiopathy; 4 had a bioprosthetic valve. The primary focus of infection was pneumonia in 10 (33.3%), and meningitis was noted in 12 (40.0%). Half the patients suffered from chronic alcoholism. Echocardiography detected vegetation(s) in 29 cases (96.7%), valvular perforation in 6 (20.0%), and/or valve ring abscess in 4 (13.3%). The most frequent complications were congestive heart failure (n = 19), large arterial emboli (n = 8), and focal abscesses (n = 7). Five strains were penicillin-resistant. Twenty (66.7%) patients underwent valve replacement, 12 of them during the first month. The overall mortality rate was 24.1%. According to a multivariate analysis, the risk factors independently associated with dying were age > or = 65 yr and septic shock, while cardiac surgery was protective (p < 0.01). In conclusion, PE is usually fulminant and causes severe valve damage and embolic complications; its short-term prognosis might be improved by early valve replacement.

Adult↗
PubMed2000

Perivalvular abscesses due to Staphylococcus aureus endocarditis comparison with Streptococcus viridans endocarditis and incremental value of transesophageal echocardiography.

BACKGROUND: Perivalvular abscesses are major complications of infective endocarditis (IE). The prevalence and best approach to detection of this complication in Staphylococcus aureus (SA) in comparison to Streptococcus viridans (SV) IE is unclear. METHOD: Among 243 consecutive episodes of IE diagnosed using the Duke criteria, who underwent either transthoracic (TTE) or transesophageal echocardiography (TEE) at the Mayo Clinic between 1988 and 1993, there were 64 cases of SV and 61 of SA IE. Comparison of TTE and TEE detection of abscesses were restricted to patients with either surgical or autopsy examination and both TTE and TEE were performed. RESULTS: Prosthetic valve and valve repair were significantly higher in SA compared to SV IE (46 vs 23%, P = 0.008). The prevalence of abscesses was higher in SA compared to SV IE (42 vs 14%, P = 0.08). 1 (10%) of abscess detected by TTE in SA compared to 1 (50%) in SV IE and 6 (60%) by TEE in SA and 1 (50%) in SV IE. Incremental value of TEE vs TTE was higher in SA 5/24 (21%) than in SV IE 0/14 (0%) P = 0.067. Hospital mortality was significantly higher in SA than SV IE (13 vs 2%, P = 0.013). CONCLUSION: Patients diagnosed with IE and those with SA 1) presented more often with prosthetic valve IE, 2) developed more perivalvular abscesses, and 3) had a higher in hospital mortality than those with SV. Incremental value of TEE was higher in SA than in SV IE, 4) therefore, had a stringent requirement for initial and repeated TEE to detect this ominous complication of IE.

Abscess↗
PubMed1992

[Indium-111 or Tc-99m-HMPAO marked granulocytes as specific markers of florid stage endocarditis--results comparing clinical, histological and scintigraphic findings in 30 patients with suspected endocarditis].

Thirty patients with clinically suspected infective endocarditis were scanned with Indium-111- or Tc-99m-HM-PAO-labeled granulocytes. The scans were correlated with the clinical course, and in 20 cases with the results from histologic examination of the valves. In six cases the scintigraphic examination gave correct positive results, in three cases false negative, in one case a false positive, and in 20 cases correct negative results. If we limit the analysis to only the histologically proven cases, our data suggest a specificity of the method of 86% and a sensitivity of about 67%.

Abscess↗
PubMed1982

Experimental endocarditis in rabbits. 6. Results of long-term combined therapy of Streptococcus faecalis endocarditis with penicillin and streptomycin.

The synergistic action of penicillin and streptomycin was investigated on animals with experimental endocarditis, using the previously described model and four different strains of Streptococcus faecalis. Two strains represented a moderate and two strains a high level of resistance to streptomycin. The purpose was to determine the effect of the combined penicillin and streptomycin treatment, since previous in vitro investigations showed that strains highly resistant to streptomycin were also resistant to combination of the drugs. Antibiotic treatment of the animals was carried out for 28 days, followed by a period of four weeks observation. The treatment resulted in a demonstrable effect against infection caused by the least streptomycin-resistant strain, but was completely ineffective in rabbits infected with the strain homogeneously resistant to 8000 micrograms/ml streptomycin. The synergistic effect of penicillin and streptomycin towards strains within a range of streptomycin resistance of 2000-8000 micrograms/ml could be predicted by the IC50 test, but not by MIC or the in vitro killing curve test for synergism. Besides the therapeutic results, this report also considers the following features: pathoanatomic and physiologic processes related to the number of viable bacteria in the endocardial vegetations; the influence of the proteolytic capacity of infecting strains; the development of congestive heart failure.

Animals↗
PubMedDate not supplied

[Aminoglycoside determinations calculated in endocarditis vegetations. Relations with clinical practices during infectious endocarditis treatment with amikacin].

Using a new computer program SPHERE, amikacin concentrations have been computed at various layers of simulated endocardial vegetations. Inputs are the computed serum (central compartment) concentrations of either population pharmacokinetic models or of individualized patient-specific models utilizing Bayesian fitting to data of doses given and measured serum levels, using the USC*PACK PC Clinical Programs. The vegetation is modeled as an isotropic homogeneous sphere. Fick's second law of radial diffusion was applied to compute the in situ antibiotic concentrations. Examination of factors affecting concentrations in vegetations shows that in situ peak concentrations are less when the vegetation is larger, and when the antibiotic dose, serum concentrations and diffusivity are all less. The results show that early and aggressive treatment of infectious endocarditis is required with high doses of concentration-dependent antibiotics, such as aminoglycosides, to achieve the desired high peak serum levels and to reach effective concentrations deep inside the vegetations.

Amikacin↗