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PubMed2006

[Infective endocarditis and outpatient practice].

The incidence of infectious endocarditis is fairly stable over the past decades. It is estimated at roughly 3-4 case per patient-year. However, as a consequence of medical progress, Staphylococcus aureus endocarditis has become more prevalent. This is particularly true for health-care associated endocarditis, especially in iv-drug abusers or hemodialysis patients. Mortality (15-20% of patients in the last series) remains high. About 50% of patients undergo surgical treatment, whereas outpatient therapy is more and more frequent for highly selected subgroups of patients without complications and infected with low-risk organims. The present paper reviews in detail the epidemiology of infective endocarditis and discuss in detail the different out-patients therapies.

Endocarditis↗
PubMed2006

[Infectious tricuspid valve endocarditis in a chronic hemodialysis patient; report of a case].

We report a rare case of isolated infectious tricuspid valve endocarditis. A 67-year-old male patient with chronic renal failure complained of fever up to 38 degrees C after hemodialysis. WBC was not elevated, but CRP was increased. Transthoracic and transesophageal echocardiography for investigating his chest discomfort demonstrated a large 13 x 25 mm vegetation on the tricuspid valve. Blood culture was negative. The tricuspid valve was replaced with a bioprosthetic valve. The extensive vegetation was found in the anterior, septal and posterior cusps and diagnosed as infectious endocarditis pathologically. The postoperative course was uneventful. WBC and CRP remained normal 9 months after surgery and no signs of recurrence were observed. The cause of the infectious endocarditis seemed to be the insertion of a double lumen catheter for dialysis or the puncture of the arteriovenous shunt.

Aged↗
PubMed2000

Physicians' recommendations to patients for use of antibiotic prophylaxis to prevent endocarditis.

CONTEXT: The American Heart Association recommendations for infectious endocarditis (IE) prophylaxis, published in June 1997, sought to improve patient and physician compliance by simplifying the dosing regimen and clarifying endocarditis risk. Adherence to these updated recommendations in patients with echocardiographic verification of their endocarditis risk profile is unknown. OBJECTIVE: To determine the recommended and actual use of IE prophylaxis as reported by patients undergoing echocardiography. DESIGN, SETTING, AND PARTICIPANTS: All patients who underwent outpatient transthoracic echocardiography at a university-based tertiary hospital in Boston, Mass, during December 1997 were contacted 6 to 9 months later to respond to a survey, completed by 218 (80%) eligible subjects. MAIN OUTCOME MEASURE: Patients' report of their physicians' instructions on actual use of IE prophylaxis in accordance with patient risk category, determined by echocardiographic data. RESULTS: One hundred eight patients (49.5%) had clinical or echocardiographic findings for which prophylaxis was indicated. Of these 108 patients, 71 (65.7%) reported that they were instructed to take IE prophylaxis. Sixteen high-risk patients (88. 9%) but only 55 moderate-risk patients (61.1%) reported that they were instructed to take prophylaxis. Among the 110 negligible-risk patients, 29 (26.4%) reported that they had been instructed to take IE prophylaxis. Overall, 100 patients (45.9%) reported that they received physician instructions to take IE prophylaxis. Of those who subsequently underwent a procedure for which IE prophylaxis was indicated (n=68), 9 (13.2%) elected not to follow their physician's advice to take prophylaxis. CONCLUSIONS: We found that although most patients reported receiving instructions for IE prophylaxis use consistent with American Heart Association guidelines, IE prophylaxis overuse among negligible-risk patients and underuse among moderate-risk patients was common. Continued physician and patient education may lead to improved adherence to the current American Heart Association recommendations. JAMA. 2000;284:68-71

Antibiotic Prophylaxis↗
PubMed1984

Surgery in infective endocarditis.

Three hundred and seventy eight patients with infectious endocarditis (IE) were studied, including 299 cases of native IE [154 subacute (SIE), 145 acute (AIE)] and 79 cases of prosthetic endocarditis (PIE). One hundred and fifty patients were operated on (40%): 117 for haemodynamic complications, 10 for bacteriological indications and 23 for mixed indications (112 patients in the acute phase). Complications were more frequent in AIE than in SIE, in PIE than in native IE. Surgery is more urgent in aortic insufficiency and in Oslerian mitral stenosis (7 cases) than in mitral insufficiency. Eight tricuspid valvulectomies were performed. In 5 cases out of 11 rupture syndrome was cured without surgery. The patient's clinical condition contra-indicated surgery in 63 cases. The surgical mortality was 51/150 (34%). It was significantly lower in SIE (21%) than in AIE (39%), in native IE than in PIE (53%), after antibiotic therapy than in the acute phase. Mortality was not higher when surgery was performed before the 8th day of antibiotherapy but perivalvular leaks were more common (31% vs 4%, P less than 0.01). Mortality was higher when the culture of valve was positive than when it was negative (45% vs 26%, P less than 0.06). However, surgery should be immediately considered in cases of haemodynamic complications.

Acute Disease↗
PubMed1998

[Endocarditis in heart defects--incidence, diagnosis and prevention].

Infectious endocarditis remains a serious complication of valvular heart disease, before and after surgery, and is associated with a considerable morbidity and mortality. The incidence of endocarditis in different cardiac diseases, the modern requirements for its diagnosis, with special emphasis on the importance of echocardiography, and the guidelines for prophylaxis are reviewed and comprehensively summarized.

Adult↗
PubMed1988

Results of a prospective statewide reporting system for infective endocarditis.

To better understand the microbiology, anatomy, and demography of infectious endocarditis, we devised a prospective statewide reporting system to study these infections. Because our study design required accurate diagnosis, reliable case reporting, and a high probability of physician-to-case exposure, we enlisted the help of cardiologists, cardiovascular surgeons, and infectious disease specialists throughout Louisiana. All Louisiana members of the American College of Cardiology and the Infectious Diseases Society of America were invited to participate. Participants were supplied with a brief endocarditis report form and asked to complete the form as they saw patients with infective endocarditis. Seventy-five patients with infective endocarditis were reported for a case rate of 1.7 per 100,000 persons per year. This report analyzes the results from this one-year study.

Adolescent↗
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↗
PubMed1994

Osteomyelitis and infective endocarditis.

Osteomyelitis is thought to occur as a complication of infectious endocarditis in as many as 6% of cases of endocarditis. We describe this association in three patients. Osteomyelitis may be difficult to diagnose in patients with endocarditis because symptoms such as fever, bone pain and stiffness are common to both illnesses, therefore physicians need to have a high index of suspicion to avoid missing this important complication. We recommend that patients with endocarditis and persistent or localized musculoskeletal symptoms should be investigated to exclude osteomyelitis. Plain radiographs can be normal in 50% of cases of osteomyelitis in the early stages or show only minor abnormalities, but bone scans are highly sensitive. We suggest that a bone scan is performed if radiography is unhelpful, since a diagnosis of osteomyelitis can effectively be excluded if the bone scan is normal. We advocate close follow-up of these patients with prolonged antibiotic treatment consisting of at least 6 weeks of intravenous therapy, and 3 months or longer of oral therapy.

Administration, Oral↗
PubMed2000

[Infective endocarditis: the course].

AIM: Epidemiological analysis of mortality due to infectious endocarditis (IE) and the disease evolution. MATERIAL AND METHODS: A retrospective analysis was made of 109 IE lethal outcomes for 1987-1996 basing on the results of autopsies performed in Kemerovo prosectorium. RESULTS: A significant trend to a rise in death rate of IE was registered. Among the deceased there is a higher proportion of old IE patients and patients with primary IE. Many of the patients died of staphylococcal IE, greater number of patients died of gram-negative infection and IE caused by injections of narcotic drugs. CONCLUSION: Long-term trends in IE evolution are described.

Adolescent↗
PubMed1996

[Early and late results of surgical intervention for 32 active infective endocarditis patients in last 10 years].

Thirty-two active infectious endocarditis patients who underwent 36 surgical procedures (23 NVEs, 13 PVEs) in last 10 years were reviewed. Seven patients (19.4%) died early postoperatively, 3/23 (13%) in NVEs and 4/13 (31%) in PVEs, and the causes of death were LOS in 5, MOF in one and cerebral bleeding in one. NVE patients of double valve deterioration who developed cardiogenic shock had poor operative results, 3 death in 4 (75%) despite of circulatory assist. Aortic PVEs who underwent Danielson's translocation technique also showed 3 death in 4 (75%). Five in 25 survivors (20%) developed late death and 3 of them were related with reinfection of prosthetic valve. We concluded that surgical treatment for active IE provides reasonable results, although they are still challenging for double valve NVEs and aortic PVEs, for which aortic root replacement using homograft would be the procedure of choice.

Adolescent↗
PubMed1979

Endocarditis involving a left ventricular apicoaortic valve-bearing conduit.

Fatal infectious endocarditis involving a left ventricular apicoaortic valve-bearing conduit occurred in a 20-year-old man. Risk factors included early postoperative wound infection, broad spectrum suppressive antibiotic administration, and inadequate dental prophylaxis against infectious indocarditis. Palliative therapy included intravenous antibiotic administration and removal of the conduit. Lessons learned are discussed.

Adult↗
PubMed1979

Comparison of two-dimensional and M-mode echocardiography in the evaluation of patients with infective endocarditis.

M-mode and two-dimensional echocardiographic evaluation of infectious endocarditis and its complications was reviewed. In 21 consecutive patients with clinical endocarditis, 22 valves were involved (12 aortic, 5 mitral and 5 tricuspid). M-mode echocardiography detected vegetations in 10 patients (four aortic, two mitral and four tricuspid) and detected complications of endocarditis in 2 patients (one aortic root abscess and one flail aortic cusp). Two-dimensional echocardiography detected vegetations in 9 patients (four aortic, one mitral and four tricuspid) and detected complications in ten patients (five flail aortic cusps, one aortic root abscess, one sinus on Valsalva aneurysm, two flail mitral leaflets and one flail tricuspid valve). Thus, although M-mode and two-dimensional echocardiography had a similar ability to detect actual vegetations, two-dimensional echocardiography was superior to M-mode echocardiography in diagnosing complications of the destructive process.

Aortic Valve↗
PubMed1994

[Infective endocarditis and drug addiction].

A total of 103 patients (P) with infectious endocarditis (IE) were treated during the period 1982-1993; 72% of them were male. Mean age was 46.4 (SD 19.7). Eighteen patients were intravenous drug addicts (D) (17.5%). The first case of drug addiction in the IE group was seen in 1986; since then, there was a steady increase of this condition, reaching 50% of all cases. The average age of D patients was 28.17 +/- 8.15 years significantly lower than that corresponding to non-drug addicts (ND), 48.64 +/- 19.5 (p < 0.00001). The infection was located mainly in the left heart of the ND (93%), and in the right heart of the D (78%), the difference being statistically significant. All the cases of left IE occurred on previously damaged valves. Right location in ND was found in all cases in immunosuppressed individuals being treated for systemic diseases, except in one patient having an endocavitary pacemaker. No differences were found between ND and D with regard to the presence of fever, cutaneous manifestations, splenomegaly or cerebrovascular accident. Differences were noted, however, in the case of respiratory involvement, which showed a significantly higher frequency in D (38.9% versus 12.9%; p < 0.014). Blood cultures were positive in 81.6% of the total number of patients, no difference being found between the two groups. Staphylococcal infections were predominant in D (44%) and streptococcal infections in ND (48%), the difference being statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2002

[Highly aggressive early prosthetic endocarditis by S. epidermidis].

Prosthetic valve endocarditis is considered to be 15% of all infectious endocarditis in developed countries, more frequently during the first 45 days after surgery. Between 45 and 60% of patients with prosthetic valve endocarditis present periannular involve. The aortic valve injury and early symptoms onset after surgery are related with a higher power of aggressive prosthetic endocarditis invasion. We present the case of a patient affected with early aortic prosthetic valve endocarditis by S. epidermidis with a high aggressive and proliferating course, accompanied by fistula to left atrial, severe aortic regurgitation and left atrial roof rupture detected at the time of surgery, along with interventricular membranous septal defect.

Endocarditis, Bacterial↗
PubMed2002

Formation of vegetations during infective endocarditis excludes binding of bacterial-specific host antibodies to Enterococcus faecalis.

Infectious endocarditis is a microbial infection of the endothelial lining of the heart that typically occurs on damaged or prosthetic heart valves. The characteristic lesion seen with infective endocarditis, termed "the vegetation," is composed of bacteria surrounded by a platelet/fibrin layer attached to the underlying endothelium. The vegetation has long been believed to exclude or hinder host defenses from clearing bacteria, although formal demonstration of mechanisms by which this occurs are lacking. This study investigated the ability of the vegetation to exclude host antibodies specific for the bacterial surface protein aggregation substance in vivo during experimental endocarditis caused by Enterococcus faecalis. The results demonstrate that, once the vegetation encloses bacteria, they are no longer accessible to high-titer bacterial-specific host antibodies, establishing a mechanism by which the vegetation functions to protect the bacteria from the humoral immune response.

Animals↗