Clostridial endocarditis. Report of a case caused by Clostridium bifermentans and review of the literature

A case of Clostridium bifermentans endocarditis occurred in a 23-year-old man who was an intravenous drug user. There was no history of preexisting valvular heart disease. He was initially treated with high-dose penicillin G potassium but remained bacteremic for a ten-day period. The bacteremia resolved when the therapy was changed to metronidazole hydrochloride. A review of the 16 reported cases of clostridial endocarditis showed no predisposing host factor to the development of the disease. Penicillin is the treatment of choice for clostridial endocarditis, but metronidazole should be considered as an alternate therapy for treatment that fails.     

Experiences in the management of subacute bacterial endocarditis treated with penicillin

Experiences are related in the management of thirty-five patients with subacute bacterial endocarditis treated solely with penicillin on the wards of the Johns Hopkins Hospital. Attention is called to the difficulty of establishing a clinical diagnosis at an early stage of the disease due to the nonspecific or misleading character of the presenting symptoms, the frequent absence of classical physical findings and the prevalence of the infection in individuals with only a minimal degree of cardiac disease. The importance of early diagnosis and institution of treatment is emphasized, as continuation of infection may result in irreparable damage to the heart or kidneys or allow the occurrence of fatal emboli, although in several instances a successful therapeutic result was achieved despite a long lapse of time from the onset of disease until commencement of therapy. It is suggested that any patient with a cardiac murmur and a persistent fever should be suspected of having bacterial endocarditis until careful bacteriologic studies and clinical observations have proved otherwise. The necessity of retaining, both aerobically and anaerobically, all blood cultures for a period of not less than three weeks before they are considered sterile is emphasized as is the importance of searching for unusual organisms such as the genus Bacteroides. The course of these patients during treatment is described and the complications encountered are analyzed relative to adequacy or inadequacy of treatment received. The conclusion is reached that the two major causes of death were the underlying cardiac disease and the persistence of bacterial endocarditis. Hence, the major therapeutic concern is that adequate penicillin be given for an adequate period of time and prior to the development of unalterable cardiac abnormalities. The fact that evidence of active bacterial endocarditis was found upon autopsy examination of three patients who died while receiving treatment commonly regarded as adequate has led to critical appraisal of present criteria of therapeutic adequacy. A plan of therapeutic management is described which is thought to assure adequate therapy for the maximum number of patients. In it the penicillin dosage is based primarily upon clinical evidence of satisfactory response. Such factors as the penicillin sensitivity of bacteria, penicillin blood levels and sterilization of blood cultures have been found to have only limited value. The necessity of continuing treatment for an adequate period of time is discussed and the recommendation is made that 100,000 units of penicillin given intramuscularly every two hours for eight weeks be considered the basic and minimal treatment schedule. The pros and cons of initiating treatment before a bacteriologic diagnosis is completed are stated with the conclusion that a reasonable period of delay is justified provided the condition of the patient does not contraindicate such treatment. It is advised that blood cultures be obtained before antibiotic therapy is given to any patient with valvular or congenital heart disease who has a localized bacterial infection, lest a latent bacterial endocarditis be obscured. The value of prolonged convalescence to allow maximal healing of damaged valves is indicated. Consideration is given to the need for adequate prophylaxis against the development of subacute bacterial endocarditis not only during dental extractions but during any type of procedure which might result in transient bacteremia. The elimination of foci of infection which might serve as a reservoir of infection or reinfection is recommended. In conclusion, the immediate results of treatment are discussed and the course of surviving patients over a three to thirty-six months' period is described. An evaluation is attempted of the influence upon the ultimate outcome of certain factors, including the presence of cardiac failure before, during and after the onset of bacterial endocarditis. The final determinants of failure or success in the treatment of subacute bacterial endocarditis with penicillin appear to be the degree of cardiac damage resulting either from the bacterial infection or an underlying disease process, the severity of the embolic occurrences and the resistance of the infecting organisms.     

Late occurrence of fatal aortitis: a complication of Aspergillus endocarditis following coronary artery bypass graft surgery

The most common fungal organism to cause endocarditis is Candidawhich is followed by Aspergillus. Aspergillus endocarditis canoccur in either the native or prosthetic heart valves, usuallyoccurs post-operative after cardiac valve surgery. This caseis illustrative of a 49-year-old man with previous history ofcoronary artery bypass grafting presenting with aortic valveendocarditis which was diagnosed as Aspergillus endocarditis.Unfortunately, despite medical and surgical therapy, progressivefatal aortic invasion occurred.     

Penicillin-sensitive Moraxella prosthetic endocarditis. Near disaster caused by failure to treat with penicillin.

A patient with late prosthetic endocarditis resulting from Moraxella non-liquefaciens is reported. Correct laboratory indentification is of therapeutic importance as Moraxella is often highly sensitive to penicillin. Because of suspected penicillin sensitivity, antibiotics other than penicillin were used, but failed to control the endocarditis. Prompt response occurred when penicillin was given. Penicillin remains by far the most effective antibiotic for the treatment of endocarditis, particularly when affecting prosthetic valves, and caused by organisms sensitive to penicillin.     

Streptobacillus moniliformis Endocarditis in an HIV-Positive Patient

Summary Streptobacillus moniliformis is the causative agent of rats bite fever, with endocarditis being a rare but well-documented complication. We report the case of an HIV-positive man who acquired S. moniliformis endocarditis through a rat bite. No predisposing cardiac lesion was known. He was treated with ceftriaxone 2g/day iv for 3 weeks, gentamicin 120 mg/day iv for 2 weeks and penicillin 24 × 10⁶ units/day for 1 week. At the end of the antibiotic therapy he suffered a generalized Candida albicans infection, which was treated with fluconazole for 1 week. He was subsequently discharged in a satisfactory condition. Received: May 20, 2000 · Revision accepted: August 7, 2000     

Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990s

Prosthetic valve endocarditis is considered to be associatedwith a more severe prognosis than native valve endocarditis.Among other factors, inappropriate visualization of vegetationsin prosthetic valve endocarditis by transthoracic echocardiographyis responsible for this observation. Since the introductionof transoesophageal echocardiography into clinical practicethe diagnostic sensitivity and specificity of the detectionof vegetations located on prosthetic valves have been enhanced.Therefore we aimed to determine and compare the prognosis ofprosthetic valve endocarditis and native valve endocarditisin the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104patients were seen at our institution between 1989 and 1993.Eighty patients (77%) had native valve endocarditis and 24 (23%)had late prosthetic valve endocarditis. In the latter grouptwo patients had recurrent infective endocarditis. Patientswith prosthetic valve endocarditis were older (mean age 64 vs54 years in native valve endocarditis; P<0.00l) and the majoritywas female (62% vs 38% in native valve endocarditis; P<0.001In prosthetic valve endocarditis, infection of a valve in themitral position predominated (65% vs 30% in native valve endocarditis;P<0.0l), whereas in native valve endocarditis more than halfthe cases had isolated aortic valve endocarditis (51% vs 27%in prosthetic valve endocarditis; P<0.01). In prostheticvalve endocarditis more cases were caused by Staphylococcusaureus (31% vs 14% in native valve endocarditis; P<0.08),whereas in native valve endocarditis the most frequent organismswere streptococci (29% vs l9% in prosthetic valve endocarditis;P<0.12). Differences in the clinical features of native valveendocarditis and prosthetic valve endocarditis could not befound except for a higher rate of embolism in native valve endocarditis(40% vs l9% in prosthetic valve endocarditis; P<0.05). Vegetationscould be detected by transthoracic echocardiography more frequentlyin native valve endocarditis (71% vs 15% in prosthetic valveendocarditis; P<0.0001). Transoesophageal echocardiographyvisualized vegetations in 95% of the episodes of native valveendocarditis and in 80% of the episodes of prosthetic valveendocarditis (P<0.09). Thus, the diagnostic gain by transoesophagealechocardiography was greatest in prosthetic valve endocarditis.Patients with native valve endocarditis had significantly largervegetations than patients with prosthetic valve endocarditis(P<0.05 for length, P<0.00l for width). The median timeto diagnosis was similar in native valve endocarditis and prostheticvalve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditisand in 58% of those with prosthetic valve endocarditis; themedian time delay between the diagnosis of infective endocarditisand surgery tended to be shorter in prosthetic valve endocarditisthan in native valve endocarditis (45 vs 60 days). The in-hospitalmortality and the mortality during a follow-up of 22±10 months did not significantly differ between native valveendocarditis and prosthetic valve endocarditis (21% vs 17% 28%vs 25%). In summary in the era of transoesophageal echocardiography,late prosthetic valve endocarditis does not seem to carry aworse prognosis than native valve endocarditis. This can beattributed in part to the improved diagnostic accuracy achievedby transoesophageal echocardiography leading to comparable diagnosticlatency periods in both patient groups. Finally, better characterizationof vegetations on prosthetic valves by transoesophageal echocardiographyallows early lifesaving surgery in patients with prostheticvalve endocarditis.     

Neisseria mucosa endocarditis

A case of Neisseria mucosa tricuspid valve endocarditis in an intravenous drug abuser is described. The patient was treated initially with intravenous penicillin G followed by oral penicillin VK but relapsed. He was cured after 4 weeks of combined therapy with penicillin G and gentamicin. In vitro synergy studies performed on the patient's and two other isolates revealed synergy in all three. Thus, combination therapy is recommended for treatment of recalcitrant cases of bacterial endocarditis caused by N. mucosa.     

Active infective endocarditis remaining latent for six weeks after discontinuation of antibiotic therapy: a case report

A 75-year-old man was treated for 4 weeks with penicillin administration for infective endocarditis in the mitral valve caused by Enterococcus faecalis. The infection recurred, so he received penicillin administration for a further 6 weeks. He remained afebrile and all laboratory examinations were within normal limits for 6 weeks after the antibiotic treatment was discontinued, but the vegetation remained large and highly mobile. Since the onset, possible embolic episodes had occurred three times. He underwent mitral valve repair with annuloplasty. Although the infection appeared to have healed by antibiotic therapy, resected tissue was strongly positive for Enterococcus faecalis. This case suggests that surgery should be aggressively considered if the vegetation does not shrink markedly.     

Streptobacillus moniliformis endocarditis. Apropos of 2 cases

The authors report two cases of endocarditis secondary to Streptobacillus moniliformis. A 41 year-old man, bitten by a rat, is hospitalized 5 weeks later for an endocarditis demonstrated by echocardiography, with massive aortic escape and hemodynamic failure requiring emergency valve replacement: after a favorable course, the patient dies suddenly 4 months later. A 63 year-old woman is admitted for a septicemic syndrome with sterno-clavicular arthritis which occurred 10 days after a rat bite; followed by a transient ischemic cerebral vascular accident; echocardiogram shows a clubshaped bulge of the distal end of the large mitral valve; the course is uneventful under antibiotherapy. In both cases, blood cultures isolate a Streptobacillus moniliformis. Infections secondary to Streptobacillus moniliformis are rare; this Gram negative bacillus, saprophyte of the rat's rhinopharynx, is transmitted to man, most of the time, by bite, and this causes a septicemia, the evolution of which is usually favorable. Complications, especially endocarditis, are exceptionally rare: only 12 cases are found in the world's literature. The evolution is always fatal in the absence of treatment which must include the association penicillin-aminoside. Prophylaxis of this disease is provided by penicillin antibiotherapy which should be systematic after a rodent's bite.     

Prosthetic Valve Endocarditis with Valvular Obstruction after Transcatheter Aortic Valve Replacement

Patients with severe aortic stenosis who are at high risk for open-heart surgery might be candidates for transcatheter aortic valve replacement (TAVR). To our knowledge, this is the first report of Streptococcus viridans endocarditis that caused prosthetic valve obstruction after TAVR.A 77-year-old man who had undergone TAVR 17 months earlier was admitted because of evidence of prosthetic valve endocarditis. A transthoracic echocardiogram revealed a substantial increase in the transvalvular peak gradient and mean gradient in comparison with an echocardiogram of 7 months earlier. A transesophageal echocardiogram showed a 1.5-cm vegetation obstructing the valve. Blood cultures yielded penicillin-sensitive S. viridans. The patient was hemodynamically stable and was initially treated with vancomycin because of his previous penicillin allergy. Subsequent therapy with levofloxacin, oral penicillin (after a negative penicillin skin test), and intravenous penicillin eliminated the symptoms of the infection.Transcatheter aortic valve replacement is a relatively new procedure, and sequelae are still being discovered. We recommend that physicians consider obstructive endocarditis as one of these.     

A case of infective endocarditis in a farmer caused by Streptococcus equinus

The following is a case report of a farmer with documented aorticvalve disease who developed bacterial endocarditis secondaryto Streptococcus equinus. This is a rare pathogen in man andits acquisition in this case may be related to the subject'soccupation.     

Penicillin therapy for treatment of experimental endocarditis caused by viridans streptococci in animals

We studied the efficacy of penicillin and penicillin combined with streptomycin in the treatment of experimental endocarditis caused by viridans streptococci that are susceptible, tolerant, or relatively resistant to penicillin. Rabbits with experimental endocarditis were treated with procaine penicillin (1.5 X 10(5) U/kg) administered twice daily or with procaine penicillin (1.5 X 10(5) U/kg) plus streptomycin (20 mg/kg) administered twice daily for five days. Compared with control animals, animals treated with penicillin alone experienced a significant reduction (P less than .001) of colony forming units per gram of cardiac valve vegetations when infected with streptococci that are susceptible, tolerant, or resistant to penicillin. This antibiotic alone was less effective against streptococci that were tolerant or resistant to penicillin than against streptococci susceptible to the drug (P less than .01). The combination of penicillin and streptomycin was more effective therapy than was penicillin alone in animals with penicillin-tolerant or penicillin-resistant streptococci causing endocarditis (P less than .01). Penicillin-streptomycin therapy was less active against penicillin-resistant strains than against either penicillin-tolerant (P less than .04) or penicillin-susceptible (P less than .01) strains. The results of our study suggest that tolerance or relative resistance to penicillin in strains of viridans streptococci influences the response to therapy with penicillin alone or penicillin combined with streptomycin in the treatment of experimental endocarditis caused by viridans streptococci.     

First reported case of bacterial endocarditis attributable to Actinomyces meyeri

A 48-year-old man presented to the Victoria General Hospital, Halifax, Nova Scotia in severe congestive heart failure. Echocardiographic studies revealed significant aortic valve insufficiency. Two anaerobic blood cultures performed two weeks apart were both positive for Actinomyces meyeri. The patient was treated with high dose intravenous penicillin. Three weeks after antibiotics were begun, he underwent aortic valve replacement. Intraoperative cultures were negative. Histopathological examination revealed findings in keeping with subacute bacterial endocarditis. The patient completed a six-week course of penicillin and was doing well three months after surgery. This is the first case of endocarditis attributable to A meyeri reported in the literature.     

Successful ceftriaxone therapy of endocarditis due to penicillin non-susceptible viridans streptococci

Viridans streptococci are a major cause of infective endocarditis, and penicillin non-susceptibility is increasing in these organisms. We present the initial reported case of infective endocarditis due to penicillin non-susceptible viridans streptococci successfully treated with ceftriaxone monotherapy. The lack of evidence supporting the recommendations for treatment of endocarditis due to penicillin non-susceptible viridans streptococci is discussed.     

Infective endocarditis due to Abiotrophia defectiva: a report of two cases

BACKGROUND AND AIM OF THE STUDY: Endocarditis due to Abiotrophia sp. is rare and often associated with negative blood cultures. The rates of treatment failure, infection relapse and mortality are higher than in endocarditis caused by other viridans streptococci. METHODS: A retrospective review of A. defectiva endocarditis in a patient with prosthetic aortic valve and in a patient with Marfan syndrome was performed. RESULTS: A. defectiva, susceptible to penicillin (MIC 0.064 mg/l and 0.016 mg/l, respectively) was isolated from blood cultures of both patients. Treatment with penicillin and gentamicin was started in both patients. Since the first patient developed a macular rash and leukopenia, penicillin was substituted with ceftriaxone. Both patients responded well to antibiotic treatment, did not need prosthetic valve insertion or reinsertion, and were without any sequelae at one year follow up. CONCLUSION: Standard treatment of bacterial endocarditis with penicillin and gentamicin was effective in both patients. In contrast to previous reports, the present patients had a favorable outcome on completion of treatment and at one-year follow up.     

A novel mechanism of resistance to penicillin-gentamicin synergism in Streptococcus faecalis

A patient with enterococcal endocarditis, who relapsed after repeated courses of apparently adequate treatment with ampicillin plus gentamicin, was subsequently cured with ampicillin-tobramycin therapy. The organisms isolated from this patient were strains of Streptococcus faecalis that were resistant to penicillin (or ampicillin)-gentamicin synergism but not to penicillin (or ampicillin)-tobramycin synergism. The mechanism of resistance in these strains appears to be related to a specific defect in the intracellular uptake of gentamicin (but not tobramycin) in the presence of penicillin.     

Survey of infective endocarditis in the last 10 years: analysis of clinical, microbiological and therapeutic features

Infective endocarditis still presents problems with early diagnosis, selection of antibiotics and timing of surgical procedure despite modern antibiotics and investigative procedures. A retrospective study was performed to clarify the clinical and microbiological spectrum of recent infective endocarditis in the Japanese population in 38 patients with infective endocarditis (mean age 42.7 +/- 12.5 years) treated from March 1986 to March 1996. The portal of entry to bacteremia was unknown in most cases (57.9%), but the commonest identified portal was dental procedure (18.4%). Overall, the aortic valve was infected most frequently (44.7%) and followed by the mitral valve (36.8%). The most common complication of infective endocarditis were emboli (11/38, 28.9%) and congestive heart failure, NYHA class III and IV (14/38, 36.8%). Organisms were isolated from 26 of the 38 (68.4%) patients. Streptococcus viridans was the most frequent organism (34.2%), and then Staphylococcus aureus (13.2%). The blood culture positivity of microorganism was significantly higher in patients not receiving antibiotics than in those the received antibiotics (87.5% vs 50%, p < 0.05). The prevalence of streptococcal endocarditis decreased in the 1990s (1992-1996) in comparison with those in the 1980s (1986-1988). Multiple antibiotics were used frequently in 1990s and the sensitivity titer to piperacillin reduced from 3.0 in the 1980s to 1.8 in the 1990s. In contrast to reduction of streptococcal endocarditis, Staphylococcus aureus endocarditis has increased recently from 12.5% to 30.8%. The most common clinical features are valve destruction, low sensitivity of penicillin, and significantly higher in-hospital mortality. Surgical treatment was indicated most commonly in cases of uncontrollable heart failure, and infected valves were replaced during the active stage in 11/23 cases (47.8%). In-hospital mortality was higher in the medical treatment group than in the surgical group, but a long-term mortality of mean observation term 4.2 +/- 3.2 years was identical in the chronic phase. In patients with infective endocarditis and successful treatment in the acute stage, a long-term survival rate in medically treated patients was found almost comparable to surgically treated patients in our series. However, it should be emphasized that streptococcal endocarditis is being replaced by infection by Staphylococcus aureus, which is resistant to penicillin and requires intensive chemotherapy and proper decision at suitable timing for surgical therapy in the early stage.     

Characteristics of infective endocarditis in France in 1991: A 1-year survey

Objective: To update data on incidence and cliar act eristicsof infective endocarditis in France. Background: Numerous studies have shown that the incidence andcourse of infective endocarditis remain stable in spite of advancesin treatment and of prophylactic recommendations. Methods: A survey of all consecutive cases of infective endocarditiswas conducted over 12 months in all the institutions of threeFrench regions. Results: Data were collected from 415 cases of definite (32%),probable (53%), and possible (15%) infective endocarditis. Theadjusted annual incidence was 24–3 cases per million inliabitants.Thirty-four percent of tlxe patients had no previously knownheart disease, 33% Iiad native valve disease, 22% had a prostheticvalve, and 11% had miscellaneous underlying conditions. Infectiveendocarditis was located solely on the mitral valve in 39%,solely on the aortic valve in 36%, and on the tricuspid valvein 6%. Echocardiography showed a vegetation on the mitral valvein 39%, on the aortic valve in 29%, and on the tricuspid valvein 8%. The causal microorganism was identified in 92%; it wasa Streptococcus in 58%, and a Staphylococcus in 23%. Twentypatients were intravenous drug users, and 45 Iiad had a medicalor a surgical procedure, which might be associated with theoccurrence of infective endocarditis. During the first 2 montlisafter admission, 24% of the patients underwent surgery, and17% of all patients died. Conclusions: Despite medical and surgical advances, infectiveendocarditis remains frequent and severe in France.     

Cardiobacterium hominis endocarditis presenting as acute embolic stroke: A case report and review of the literature

We report on a case of endocarditis attributable to Cardiobacterium hominis in a 31-year-old man who presented with acute-onset, left-sided hemiparesthesia. Magnetic resonance imaging of the brain showed acute infarctions in 2 areas of the right cerebral cortex, and a transesophageal echocardiogram revealed vegetation in a previously unrecognized bicuspid aortic valve. The patient completed a 6-week course of ceftriaxone and aspirin, with resolution of the vegetation and neurological complications. Our literature review of C. hominis endocarditis suggests that aortic-valve involvement is associated with high stroke and valve-surgery rates. Favorable outcomes and treatment success are evident with either penicillin or ceftriaxone, in combination with (if indicated) valve surgery in patients with neurological complications.     

Short-term success, but long-term treatment failure with linezolid for enterococcal endocarditis

We report a case of linezolid treatment failure for Enterococcus faecalis endocarditis. Despite success during and shortly after treatment, the patient had a relapse after 7 weeks. Due to prior anaphylactic reaction to penicillin, desensitization was performed, and successful penicillin therapy given. The efficacy of linezolid for enterococcal endocarditis remains questionable.