Cardiovascular Implantable Electronic Device Infection in Patients with Staphylococcus aureus Bacteremia

Background: Staphylococcus aureus bacteremia (SAB) in patients with cardiovascular implantable electronic devices (CIED), including permanent pacemakers (PPMs) and implantable cardioverter‐defibrillators (ICD), can be the sole manifestation of device infection. Methods: To assess clinical factors associated with CIED infection, we retrospectively reviewed all patients with both CIED and SAB seen at Mayo Clinic Rochester between 2001 through 2006. CIED infection was defined using microbiological and clinical criteria. Results: Of the 62 patients with SAB and a CIED, 22 patients (35.5%) had CIED infection. The generator pocket was identified as the source of bacteremia in seven (11%) patients. The majority of CIED infections were device‐related infective endocarditis (12 of 22, 55%). Thirty percent of patients presenting with SAB greater than 1 year after device implantation had CIED infection; all but one had CIED‐related infective endocarditis. Sixty percent of ICD patients (12 of 20) with SAB had CIED infection, compared with 24% of PPM patients (10 of 42, P = 0.01). On univariate analysis factors associated with CIED‐related infective endocarditis included device type [odds ratio (OR) for ICD 13.3, 95% confidence interval [CI] 2.1, 84.9) and presence of a prosthetic heart valve (OR 6.8 95% CI 1.1, 43.4). Conclusions: CIED infection is common in patients with SAB. The presence of an ICD and prosthetic heart valve were associated with CIED‐related infective endocarditis. Subsequent work should focus on prospectively characterizing the subset of patients with CIED infection who present with SAB as the sole manifestation of their device infection. (PACE 2010; 407–413)     

Infective endocarditis and osteomyelitis caused by Cellulomonas: a case report and review of the literature

Cellulomonas spp. are often believed to be of low virulence and have never been reported as a pathogen causing human disease before. We report the first case of endocarditis caused by Cellulomonas and complicated with osteomyelitis of the lumbar spine in a 78-year-old woman. General weakness and aggravated lower back pain followed by sudden-onset of fever and chills were the major presentation. The diagnosis of infective endocarditis in this case was definitely using the Duke criteria. The magnetic resonance imaging of the lumbar spine revealed infective spondylodisciitis at an early stage. After a full course of antibiotics treatment, the patient's fever subsided but her lower back pain persisted. A slow clinical response to appropriate antimicrobial agents was characteristic of Gram-positive bacillary endocarditis.     

Infective endocarditis complicating permanent pacemaker and implantable cardioverter-defibrillator infection

OBJECTIVE: To describe management of patients with permanent pacemaker (PPM)- and implantable cardioverter-defibrillator (ICD)-related endocarditis. PATIENTS AND METHODS: We retrospectively reviewed all cases of infection involving PPMs and ICDs among patients presenting to Mayo Clinic's site in Rochester, MN, between January 1, 1991, and December 31, 2003. Cardiac device-related infective endocarditis (CDIE) was defined as the presence of both vegetation on a device lead or valve and clinical or microbiological evidence of CDIE. Of 189 patients with PPM or ICD infection who were admitted during the study period, 44 met the case definition for CDIE (33 PPM, 11 ICD). RESULTS: The mean +/- SD age of patients was 67 +/- 14 years. Staphylococci (36 [82%]) were the most commonly isolated pathogens. Nearly all patients (43 [98%]) were treated with a combined approach of complete hardware removal and parenteral antibiotics. The median duration of antibiotic treatment after infected device explantation was 28 days (interquartile range, 19-42 days). Device leads were removed percutaneously in 34 cases (77%); only 7 cases (16%) required surgical lead extraction. Percutaneous extraction was uncomplicated in 15 patients with lead vegetation greater than 10 mm in diameter. Six patients (14%) died during hospitalization. Twenty-seven (96%) of 28 patients remained infection free at their last visit (median follow-up, 183 days; intraquartile range, 36-628 days). CONCLUSION: Prompt hardware removal and prolonged parenteral antibiotic administration decrease mortality among patients with CDIE. The presence of a large (> 10 mm in diameter) vegetation on a lead is not a contraindication for percutaneous lead extraction.     

Staphylococcal endocarditis as the first manifestation of heritable protein S deficiency in childhood

A 12-year-old Japanese girl developed infective endocarditis and central nervous system disease. The previously healthy girl showed altered consciousness and abnormal behaviors along with the classical signs of septic emboli. Staphylococcus aureus was isolated from peripheral blood, but not, the pleocytotic cerebrospinal fluid. Diagnostic imaging studies revealed a vegetative structure in the morphologically normal heart, and multiple thromboembolisms in the brain and spleen. Low plasma activity of protein S (12%) and thrombophilic family history allowed the genetic study, demonstrating that she carried a heterozygous mutation of PROS1 (exon 13; 1689C > T, p.R474C). Surgical intervention of the thrombotic fibrous organization and subsequent anticoagulant therapy successfully managed the disease. There are no reports of infective endocarditis in childhood occurring as the first presentation of heritable thrombophilia. Protein S deficiency might be a risk factor for the development or exacerbation of infective endocarditis in children having no pre-existing heart disease.     

Neurological presentations of native valve endocarditis

In a prospective study of 178 episodes of community-acquired native valve infective endocarditis seen at St Thomas' Hospital between 1969 and 1987, 59 patients (33 per cent) presented with neurological disorders that included meningitis, toxic confusion, major thromboembolic phenomena and headache. A neurological presentation occurred in 54 per cent of all cases of staphylococcal endocarditis, but in only 19 per cent of episodes of 'viridans' streptococcal and enterococcal endocarditis. Overall one-third of patients with staphylococcal endocarditis presented with clinical features of meningitis (40 per cent with no cardiac murmur). The mortality rate for community-acquired native valve endocarditis was higher for those with a neurological presentation than without.     

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 < 0.001) and for embolic events (p < 0.001), less for mortality (p < 0.01), and lowest for abscess formation (p < 0.05). The dose of ADP to induce half-maximal platelet aggregation was significantly lower in patients with SEC (0.71 ± 0.15μl) than without SEC (1.05 ± 0.12μl;p < 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.     

Candida Infective Endocarditis: an Observational Cohort Study with a Focus on Therapy

Candida infective endocarditis is a rare disease with a high mortality rate. Our understanding of this infection is derived from case series, case reports, and small prospective cohorts. The purpose of this study was to evaluate the clinical features and use of different antifungal treatment regimens for Candida infective endocarditis. This prospective cohort study was based on 70 cases of Candida infective endocarditis from the International Collaboration on Endocarditis (ICE)-Prospective Cohort Study and ICE-Plus databases collected between 2000 and 2010. The majority of infections were acquired nosocomially (67%). Congestive heart failure (24%), prosthetic heart valve (46%), and previous infective endocarditis (26%) were common comorbidities. Overall mortality was high, with 36% mortality in the hospital and 59% at 1 year. On univariate analysis, older age, heart failure at baseline, persistent candidemia, nosocomial acquisition, heart failure as a complication, and intracardiac abscess were associated with higher mortality. Mortality was not affected by use of surgical therapy or choice of antifungal agent. A subgroup analysis was performed on 33 patients for whom specific antifungal therapy information was available. In this subgroup, 11 patients received amphotericin B-based therapy and 14 received echinocandin-based therapy. Despite a higher percentage of older patients and nosocomial infection in the echinocandin group, mortality rates were similar between the two groups. In conclusion, Candida infective endocarditis is associated with a high mortality rate that was not impacted by choice of antifungal therapy or by adjunctive surgical intervention. Additionally, echinocandin therapy was as effective as amphotericin B-based therapy in the small subgroup analysis.     

Factors other than the Duke criteria associated with infective endocarditis among injection drug users

BACKGROUND: Modified Duke criteria were applied to consecutive injection drug users (IDUs) who were admitted to an inner-city hospital with a clinical suspicion of infective endocarditis, and the presence of any other clinical variables that were predictive of the presence of infective endocarditis was determined. METHODS: Clinical data on consecutive IDUs who were hospitalized over 15 months in Vancouver were collected. Data included the admission history, and findings on physical examination and on initial laboratory investigations. Each subject's course in hospital was followed until discharge or death during the index hospitalization. Follow-up data collected included culture results, the interpretation of the echocardiogram and the discharge diagnosis. The modified Duke criteria were used for the diagnosis of infective endocarditis (definite, possible or rejected). Multiple logistic regression was used to determine what clinical variables (exclusive of the Duke criteria) available within 48 hours of presentation were independent predictors of infective endocarditis. RESULTS: One hundred IDUs were enrolled. Fifty-one were female, and 58 were HIV-positive. Twenty-three met the modified Duke criteria for definite infective endocarditis, and 25 had possible infective endocarditis. IDUs with definite infective endocarditis were more commonly noted to have evidence of vascular phenomena (arterial embolism, septic pulmonary infarction, mycotic aneurysm, intracranial hemorrhage or Janeway lesions) (6 [26%]) than those who had possible endocarditis (1 [4%]). Those with definite infective endocarditis more often had multiple opacities on chest radiography (56% v. < 12%), and fewer had an obvious source of infection (52% v. 72% and 81% of possible and rejected infective endocarditis, respectively). Among febrile IDUs, definite endocarditis was highly associated with having no obvious source of infection (odds ratio 3.1 [95% confidence interval 1.1-8.7]) compared with febrile IDUs with an obvious source of infection. In similarly compared groups, the presence of hematuria, proteinuria or pyuria was also predictive of definite endocarditis (odds ratio 2.9 [95% CI 1.1-8.6]). CONCLUSIONS: Among IDUs, the modified Duke criteria are useful for classifying cases with definite infective endocarditis and rejecting cases without infective endocarditis. The classification of possible infective endocarditis is suitable for this population.     

Tricuspid Endocarditis in an Adult Patient with Ebstein’s Anomaly who has a Residual Pacemaker Lead

Ebstein’s anomaly is defined as an apical displacement of the attachment of the septal tricuspid valve leaflet from the right atrioventricular annulus that exceeded 1.2 cm in length. Patients with Ebstein’s anomaly are known to have a high potential for developing arrhythmia, in the vast majority, of the tachycardia type. Infective endocarditis is characterized by ulcerovegetational lesions that result from the graft of a microorganism, usually bacterial, on the valvuler endocardium (native valve endocarditis) or on a prosthesis (prosthetic valve endocarditis). Ebstein’s anomaly with tricuspid regurgitation is also thought to be a predisposing condition for infective endocarditis. In this case, we report a patient who presented with atrial flutter and infective endocarditis due to residual pacemaker lead and Ebstein’s anomaly.     

Enterococcus faecalis infective endocarditis: focus on clinical aspects

Enterococcus faecalis infective endocarditis (IE) is a disease of increasing importance, with more patients infected, increasing frequency of health-care associated infections and increasing incidence of antimicrobial resistances. The typical clinical presentation is a subacute course with fever, malaise and generalized aches, difficult to distinguish from other more common diseases. Of paramount importance is transthoracic- and transesophageal-echocardiography to establish the diagnosis. At the moment, the predominant strategies recommend ampicillin in combination with either gentamicin or ceftriaxone. E. faecalis infective endocarditis continues to be a very serious disease with considerable percentages of high-level gentamicin resistant strains and in-hospital mortality around 20%. Strategies to prevent E. faecalis IE, improve diagnostics, optimize treatment and reduce morbidity will be necessary to improve the overall prognosis.     

Analysis of clinical background in patients with vegetation-like echoes: importance of clinical information

Purpose Detection of vegetation is important for diagnosing infective endocarditis.Methods We analyzed clinical information from 58 patients with vegetation-like echoes on transthoracic echocardiography who had been referred to this institution for an echocardiographic examination during the past 5 years. Patients with healed vegetations were excluded. A vegetation-like echo was defined as a mass, a thread-like echo attached to the valve or endocardium, or both. Diagnosis of a vegetation-like echo required the concurrence of two cardiologists and one sonographer. Altogether, 44 patients were treated with antibiotics because their clinical courses were consistent with active infective endocarditis.Results Blood cultures were positive in 27 patients and negative in 17 patients. Follow-up data were available for 10 of the 14 patients who had no findings suggestive of active infective endocarditis. The size of the vegetation-like echo remained unchanged over a mean interval of 12.1 months, and no clinical signs or symptoms of active infective endocarditis appeared. In about one-fourth of the patients with a vegetation-like echo, it was not associated with infective endocarditis.Conclusion Clinical information, in addition to detection of a vegetation-like echo, appears to be indispensable for diagnosing infective endocarditis.This article is a translation of the original that was published in Jpn J Med Ultrasonics 2001;28:J35–40     

Cryptococcus endocarditis: A case report and review of the literature

IntroductionCryptococcus neoformans is known to be a cause of meningitis. However, as cryptococcal endocarditis is rare, it is not well understood. Here, we describe a case with Implantable Cardioverter Defibrillator associated endocarditis and meningitis caused by Cryptococcus neoformans and we review the literature associated cryptococcal endocarditis.Case presentationA 72 years old Japanese male presented in emergency department with non-productive cough and respiratory discomfort. His past medical history was ischemic heart disease four years ago and ICD was implanted. Physical examination was unremarkable. Chest computer tomography revealed ground glass opacity in the right lung. He received a diagnosis of amiodarone-induced interstitial pneumonitis and high dose steroid pulse therapy. Septic shock and acute respiratory failure occurred after steroid therapy. Cryptococcus neoformans was identified by blood culture and cerebral spinal fluid. Intravenous liposomal Amphotericin B and oral flucytosine were initiated. Transesophageal echocardiography revealed vegetation on the lead of the ICD. Diagnosis of cryptococcal endocarditis was made. The patient died despite antifungal therapy was continued.DiscussionWe analyzed our case and 8 cases of cryptococcal endocarditis in the literature for 40 years. Almost all of the patients had previous valve replacement surgery or immunocompromised state. Three cases had meningitis. Surgery performed in 3 cases. The overall mortality rate were 44.4%.ConclusionsCryptococcal endocarditis is rare and carries a high mortality. Almost all of the patients had underlying diseases. Diagnosis needs repeating blood culture and echocardiogram, sometimes. Cryptococcal endocarditis needs lumber puncture for rule out meningitis.     

Successful laser-assisted removal of an infected ICD lead with a large vegetation

Infective endocarditis involving transvenous pacing leads is an uncommon but potentially lethal complication of implantable cardioverter-defibrillator (ICD) implantation. Complete removal of the device and the leads is presently considered to be the optimal treatment in such patients and laser-assisted lead removal is an effective and safe nonthoracotomy approach. However, large vegetations (>10 mm) attached to the lead limit nonthoracotomy explantation because of the potential for hemodynamically embarrassing pulmonary embolization. Laser extraction of leads with vegetation area >300 mm2 has rarely been reported. In this case report, we describe a patient with an infected ICD lead with vegetation greater than 41 x 12.5 mm (512 mm2) in size that was explanted with laser-assistance. The resulting pulmonary embolus produced a 33 x 20 mm pulmonary infarction without hemodynamic or respiratory compromise.     

Corynebacterium jeikeium-induced infective endocarditis and perivalvular abscess diagnosed by 16S ribosomal RNA sequence analysis: A case report

IntroductionCorynebacterium jeikeium normally presents on human skin, and it is often judged as contamination when it is cultured from blood. C. jeikeium can cause infective endocarditis, especially, that associated with cardiac surgery and prosthetic valvular endocarditis.Case reportA 66-year-old Japanese male patient was diagnosed with C. jeikeium-induced infective endocarditis (IE) and perivalvular abscess after a coronary artery bypass grafting and aortic valve replacement with bioprosthesis; pyogenic spondylodiscitis was also observed. Patch repair for aortic valve annulus and re-Bentall procedure with bioprosthesis was performed for IE and perivalvular abscess. The causative bacterium was confirmed as C. jeikeium on 16S ribosomal RNA sequencing of surgical sample and positive blood culture. The patient underwent six weeks of intravenous antibacterial treatment with vancomycin and an additional two weeks of oral treatment with linezolid, following which, his condition improved. Corynebacterium jeikeium can cause infective endocarditis and perivalvular abscess, which is a more severe condition than IE.Conclusion16S ribosomal RNA sequencing is useful in diagnosing bacterial species that can cause contamination, such as Corynebacterium spp.     

Current diagnosis and treatment of infective endocarditis

The incidence of infective endocarditis continues to rise with a yearly incidence of around 15,000 to 20,000 new cases in the USA. As a result, rapid diagnosis, effective treatment and prompt recognition of complications are essential to desirable clinical outcomes. Recent guidelines such as the Duke criteria have incorporated echocardiography for diagnosis of infective endocarditis, making this diagnostic test mandatory for patients with suspected infective endocarditis. The diversity of pathogens that can cause infective endocarditis, some of which cannot be cultured easily, makes diagnosis even more difficult. Coagulase-negative staphylococci and viridans streptococci groups continue to be the major causative microorganisms of infective endocarditis. In the case of culture-negative endocarditis or infective endocarditis caused by fastidious microorganisms, the polymerase chain reaction and probe-based diagnostic methods are available to clinical reference laboratories.     

Current diagnosis and treatment of infective endocarditis

The incidence of infective endocarditis continues to rise with a yearly incidence of around 15,000 to 20,000 new cases in the USA. As a result, rapid diagnosis, effective treatment and prompt recognition of complications are essential to desirable clinical outcomes. Recent guidelines such as the Duke criteria have incorporated echocardiography for diagnosis of infective endocarditis, making this diagnostic test mandatory for patients with suspected infective endocarditis. The diversity of pathogens that can cause infective endocarditis, some of which cannot be cultured easily, makes diagnosis even more difficult. Coagulase-negative staphylococci and viridans streptococci groups continue to be the major causative microorganisms of infective endocarditis. In the case of culture-negative endocarditis or infective endocarditis caused by fastidious microorganisms, the polymerase chain reaction and probe-based diagnostic methods are available to clinical reference laboratories.     

Fungal endocarditis after transcatheter aortic valve replacement (TAVR): Case report and review of literature

The reported number of transcatheter aortic valve replacement-associated infective endocarditis (TAVR-IE) cases has been increasing worldwide, but information about the incidence and clinical features of fungal TAVR-IE is quite limited. We present a patient who acquired TAVR-IE caused by Candida parapsilosis four month after TAVR, who was successfully treated redo-aortic valve replacement and prolonged antifungal therapy.     

Acute myocardial infarction as the first sign of infective endocarditis: a case report

Infective endocarditis is a bacterial or fungal infection of the heart valves or endocardial surface, and it frequently forms vegetation and can lead to systemic embolism. Dislodged vegetation rarely results in coronary artery embolism (CAE) and subsequent acute myocardial infarction. A 43-year-old male patient was emergently brought to our hospital for suspected acute myocardial infarction. Coronary angiography was performed and it showed embolism in the left circumflex artery. Thrombus aspiration was performed during coronary angiography. Echocardiography showed formation of vegetation in the posterior leaflet of the mitral valve and multiple blood cultures showed Listeria monocytogenes. Infective endocarditis was diagnosed. Three weeks later, debridement of subacute bacterial endocarditis, mitral valve replacement, and tricuspid valvuloplasty were successfully conducted. Our findings suggest that CAE should be considered in the differential diagnosis of acute myocardial infarction. Aspiration of coronary embolus during coronary angiography followed by surgical intervention of diseased heart valves is a plausible strategy for managing CAE in infective endocarditis.