New etiologies responsible for infective endocarditis with negative blood cultures]

The prevalence of infective endocarditis with negative blood cultures varies in the different series from 5 to 25%. There are certain explanations of negative blood culture endocarditis: previous incorrect antibiotic therapy before obtaining blood samples (antibiotic treatment inhibits the growth of germs, and therefore bacteremia, without sterilizing the vegetations); infective endocarditis due to fastidious microorganism, that is of difficult cultivation and identification; infective endocarditis due to cell-dependent organism (e.g. Coxiella burnetii); infective endocarditis due to fungi; non-infectious involvement of the endocardium (at times with vegetations) during the course of certain disease. We underline three etiologies (Coxiella burnetii, Bartonella species and Whipple's disease bacterium) because their study have constituted the stimulus for the introduction into clinical evaluation of patients with suspected infective endocarditis of different diagnostic approaches, based on a correct sequential application of blood cultures, serodiagnosis and molecular microbiology.     

Influence of diabetes mellitus on short- and long-term outcome in patients with active infective endocarditis

BACKGROUND AND AIM OF THE STUDY: The incidence and severity of certain infections appear to be increased in patients with diabetes mellitus (DM). The study aim was to evaluate the effect of DM on short- and long-term outcome in patients with active infective endocarditis (IE). METHODS: A total of 151 patients with IE was included and followed up for a mean of 3.1 years. Of these patients, 13 (9%) were diabetics. The outcome of patients with or without DM was compared at short-term (in-hospital) and long-term follow up. RESULTS: Patients with DM were older (66 +/- 11 versus 50 +/- 19 years, p < 0.01) and had a lower frequency of intravenous drug abuse (0 versus 30%, p <0.01) and tricuspid valve involvement (0 versus 20%, p = 0.02) than non-DM patients. Mortality was higher in DM patients both in hospital (31% versus 15%, p = NS) and at a mean follow up of 3.1 years (54% versus 31%, p = 0.002). DM patients also had a significantly higher rate of cardiac failure (69% versus 38%, p = 0.03) and renal failure (62% versus 20%, p <0.01) during hospitalization. Incidences of anatomic complications (abscess, pseudoaneurysm) (15.4% versus 20.3%), valve rupture or perforation (7.7% versus 16.7%) and need for surgical repair (46.2% versus 45.7%) were similar in both DM and non-DM patients. DM, without secondary pathology like renal failure, did not appear to be an independent risk factor for mortality at either short- or long-term follow up. CONCLUSION: Although mortality and morbidity in IE were greater in DM than in non-DM patients, diabetes itself does not constitute an independent risk factor.     

Infectious endocarditis with negative blood cultures

Blood culture is a key investigation for the diagnosis of infectious endocarditis (IE). When negative, there are diagnostic and therapeutic problems. The aim of this study was to determine the frequency, the clinical features and the aetiological factors of IE with negative blood cultures compared with IE with positive blood cultures compared with IE with positive blood cultures. The authors undertook a retrospective review of 98 cases of patients admitted for IE from 1991 to 2000 to the Department of Infectious Diseases and Cardiology of Sousse (Tunisia). Of the 98 patients, 48 (48.9%), 29 men and 19 women with an average age of 34.3 years, had negative blood cultures. An infectious agent was identified in 7 cases (14.5%) by serology, valve culture or cerebrospinal fluid including Brucella (2), Coxiella (1) and Candida (1). Therefore, in 41 cases (42%), the cause of IE was not determined. Transthoracic echocardiography was of diagnostic value in 96% of cases and transoesophageal echocardiography showed disease not observed on transthoracic echocardiography in 5 cases. The main complication was cardiac failure (27 cases). The mortality was 14.5%. Comparison of the two groups showed that negative blood cultures were associated with a higher incidence of previous antibiotic therapy, extracardiac signs of IE and cardiac failure. Early surgical indications and mortality were the same in both groups. This report confirmed the high frequency of IE with negative blood cultures. Previous antibiotic therapy seems to be an important aetiological factor but cannot explain this high frequency. Methodological problems of blood cultures and the absence of systematic investigation for rare infectious agents are other possible factors.     

The general characteristics and short- and long-term results of infective endocarditis in non-drug addicts

INTRODUCTION AND OBJECTIVES: Infective endocarditis is a disease with a high morbimortality during the active phase and a considerable risk of complications during follow-up. The aim of our study is to describe the clinical and prognostic features of infective endocarditis in non-drug addict patients in short and long terms. PATIENTS AND METHODS: A prospective study of 138 cases of infective endocarditis in non-drug addict patients through the parenteral pathway treated in our institution from 1987 to 1997. RESULTS: The mean age was 44 +/- 20 years. Ninety-five patients (69%) had native valve infective endocarditis and forty-three (31%) had prosthetic valve endocarditis. Streptococci were the causal microorganism in 34% and staphylococci in 33%. 83% of patients developed some type of complications during hospital stay. 51% of patients were operated on during the active phase (22% were urgent). The in-hospital mortality rate was 21%. 10 patients (9%) needed late cardiac surgery and seven patients (5%) died during follow-up. Global survival at 10 years was 71%. There were no statistical differences in survival in as much as the type of treatment received during the hospital stay in the active phase (medical alone or combined medical-surgical). CONCLUSIONS: A high early surgery rate in the active phase related to good long-term results and does not increase early in-hospital mortality. Medical treatment also offers good long-term results in cases of infectious endocarditis with absence of bad prognostic factors and good clinical outcome.     

Maximizing the yield from blood cultures in suspected infective endocarditis

The laboratory test of paramount importance in patients with suspected infective endocarditis is blood culture. This article considers the generations-old problem of the timing and frequency of these cultures, describes techniques to increase their yield, and outlines measures to take whenever special cultures fail to identify the etiologic agent.     

The impact of transoesophageal echocardiography in elderly patients with infective endocarditis

BackgroundInfective endocarditis (IE) increasingly involves older patients. Geriatric status may influence diagnostic and therapeutic decisions.AimTo describe transoesophageal echocardiography (TEE) use in elderly IE patients, and its impact on therapeutic management and mortality.MethodsA multicentre prospective observational study (ELDERL-IE) included 120 patients aged ≥75 years with definite or possible IE: mean age 83.1± 5.0; range 75–101 years; 56 females (46.7%). Patients had an initial comprehensive geriatric assessment, and 3-month and 1-year follow-up. Comparisons were made between patients who did or did not undergo TEE.ResultsTransthoracic echocardiography revealed IE-related abnormalities in 85 patients (70.8%). Only 77 patients (64.2%) had TEE. Patients without TEE were older (85.4 ± 6.0 vs. 81.9 ± 3.9 years; P = 0.0011), had more comorbidities (Cumulative Illness Rating Scale-Geriatric score 17.9 ± 7.8 vs. 12.8 ± 6.7; P = 0.0005), more often had no history of valvular disease (60.5% vs. 37.7%; P = 0.0363), had a trend toward a higher Staphylococcus aureus infection rate (34.9% vs. 22.1%; P = 0.13) and less often an abscess (4.7% vs. 22.1%; P = 0.0122). Regarding the comprehensive geriatric assessment, patients without TEE had poorer functional, nutritional and cognitive statuses. Surgery was performed in 19 (15.8%) patients, all with TEE, was theoretically indicated but not performed in 15 (19.5%) patients with and 6 (14.0%) without TEE, and was not indicated in 43 (55.8%) patients with and 37 (86.0%) without TEE (P = 0.0006). Mortality was significantly higher in patients without TEE.ConclusionsDespite similar IE features, surgical indication was less frequently recognized in patients without TEE, who less often had surgery and had a poorer prognosis. Cardiac lesions might have been underdiagnosed in the absence of TEE, hampering optimal therapeutic management. Advice of geriatricians should help cardiologists to better use TEE in elderly patients with suspected IE.     

Risk factors and prognosis of neurological complications in patients with infective endocarditis

<正>Objective To identify risk factors of neurological complications(NC)in left-sided infective endocarditis(IE)and to assess its impact on the outcome and cardiac surgery.Methods Clinical data,NC,treatment and outcome of patients with definite left-sided IE admitted to our hospital during 2001—2012 were retrospectively ana-     

Impact of perioperative liver dysfunction on in-hospital mortality and long-term survival in infective endocarditis patients

Purpose

Infective endocarditis (IE) is often associated with multiorgan dysfunction and mortality. The impact of perioperative liver dysfunction (LD) on outcome remains unclear and little is known about factors leading to postoperative LD.

Methods

We performed a retrospective, single-center analysis on 285 patients with left-sided IE without pre-existing chronic liver disease referred to our center between 2007 and 2013 for valve surgery. Sequential organ failure assessment (SOFA) score was used to evaluate organ dysfunction. Chi-square, Cox regression, and multivariate analyses were used for evaluation.

Results

Preoperative LD (Bilirubin >20 μmol/L) was present in 68 of 285 patients. New, postoperative LD occurred in 54 patients. Hypoxic hepatitis presented the most common origin of LD, accompanied with high short-term mortality. In-hospital mortality was higher in patients with preoperative and postoperative LD compared to patients without LD (51.5, 24.1, and 10.4%, respectively, p < 0.001). 5-year survival was worse in patients with pre- or postoperative LD compared to patients without LD (20.1, 37.1, and 57.0% respectively). A landmark analysis revealed similar 5-year survival between groups after patient discharge. Quality of life was similar between groups when patients survived the perioperative period. Logistic regression analysis identified duration of cardiopulmonary bypass and S. aureus infection as independent predictors of postoperative LD.

Conclusions

Perioperative liver dysfunction in patients with infective endocarditis is an independent predictor of short- and long-term mortalities. After surviving the hospital stay, 5-year prognosis is not different and quality of life is not affected by LD. S. aureus and duration of cardiopulmonary bypass represent risk factors for postoperative LD.

     

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.     

Evaluation of mitral valve lesions in patients with infective endocarditis by three-dimensional echocardiography

Recognition of the involved lesions is extremely important in mitral valve repair for infective endocarditis. Transesophageal echocardiography (TEE) is more sensitive for the detection of lesions than transthoracic echocardiography, but localization of the lesions is sometimes difficult by TEE. Three-dimensional (3D) TEE provides images of the mitral valve similar to the view from the left atrium. This study evaluated the value of 3D echocardiography for the diagnosis of involved lesions in 12 patients who underwent surgery for mitral regurgitation due to infective endocarditis. The location of the lesion in the mitral valve was classified as the medial, central and lateral portions of the anterior leaflet, and the medial, middle and lateral scallops of the posterior leaflet, respectively. In all patients, the involved sites were confirmed at operation. The sensitivities of 3D TEE for detecting the lesions at the medial, central and lateral portions of the anterior leaflet, and the medial, middle and lateral scallops of the posterior leaflet were 100%, 78% and 67%, and 100%, 100% and 100%, respectively. The specificities were 90%, 100% and 78%, and 100%, 100% and 100%, respectively. The lesions diagnosed by 3D TEE coincided with lesions confirmed at operation in 23 (92%) of 25 lesions. 3D TEE is useful for the assessment of the involved lesion of the mitral valve in patients with infective endocarditis.     

中性粒细胞VCS参数在血培养阴性感染性心内膜炎中的临床应用

目的：探讨中性粒细胞VCS等参数在血培养阴性的感染性心内膜炎疾病中的变化及临床意义。方法：使用BeckmanCoulter LH 750全自动血液分析仪对64例血培养阴性感染性心内膜炎患者,50例正常对照者进行常规血液分析。收集各组WBC总数及中性粒细胞VCS参数。对各组间均数进行t检验来判断差异有无统计学意义。结果：64例血培养阴性的感染性心内膜炎患者的WBC总数比正常对照组略高,差异有统计学意义（P〈0.05）。中性粒细胞平均体积（MNV）和体积分布宽度（MNV-SD）均明显高于正常对照组,均差异有统计学意义（P〈0.01或P〈0.05）。中性粒细胞平均传导率（MNC）也高于正常对照组,差异有统计学意义（P〈0.05）。但中性粒细胞平均光散射（MNS）与正常对照组比较差异无统计学意义（P〉0.05）。ROC曲线显示,血培养阴性的感染性心内膜炎患者的MNV的曲线面积达到0.879,MNC的曲线面积达到0.756。在MNV≥140时,其敏感性和特异性分别为80%,82%。结论：中性粒细胞VCS参数对血培养阴性的感染性心内膜炎有较好的早期诊断提示作用。     

Improved detection of infective endocarditis with transesophageal echocardiography.

The incremental advantage of transesophageal echocardiography was determined by comparing results of paired transthoracic and transesophageal echocardiographic examinations performed in 61 patients for evaluation of suspected infective endocarditis. According to clinical and pathologic data, 31 of 61 (51%) patients had finding that were positive for infective endocarditis. Studies were graded as positive or negative for vegetations and were also graded for image quality. The sensitivity of transesophageal echocardiography in detecting vegetations was 88% versus 30% for transthoracic studies (p less than 0.01). For patients with aortic valve infective endocarditis, transesophageal sensitivity was 88% versus 25% for transthoracic sensitivity, because transesophageal echocardiography successfully separated vegetations from chronic valve disease caused by sclerosis or calcification (p less than 0.01). For patients with mitral valve infective endocarditis, transesophageal sensitivity was 100% versus 50% for transthoracic sensitivity, because transesophageal echocardiography distinguished vegetations from myxomatous changes or detected vegetations on prosthetic valves (p less than 0.01). Thus transesophageal echocardiography improves recognition of infective endocarditis, particularly in the presence of underlying valvular disease.     

Influence of pathogenetic factors on prognosis in patients with native valve infective endocarditis

INTRODUCTION: Despite improvement in medical care the incidence of infective endocarditis (IE) has not decreased. Positive blood cultures are one of the most important diagnostic criteria of IE. There are no uniform data regarding the influence of pathogenetic factors on prognosis. AIM: To analyse the results of blood and valve cultures in patients with IE of native valves and evaluate their influence on the risk of early and late deaths as well as recurrence of IE. METHODS: The study group consisted of 152 patients with IE of native valves. The IE diagnosis was based on the Duke criteria. Early and late mortality as well as recurrence of IE were analysed in patients hospitalised at the Institute of Cardiology in Warsaw from 1988 to 1998. RESULTS: Positive blood cultures were found in 103 (67.8%) of patients. In-hospital mortality was 5.9% (9 deaths). The incidence of early deaths was significantly lower in surgically treated patients (p=0.01). Late deaths occurred in 23 (16%) patients. Results of blood and valve tissue cultures were not related to mortality. Recurrent IE was observed in 7 (4.9%) patients. Staphylococcus aureus was an independent risk factor for recurrent IE (p=0.04). Six-year survival was 79%. CONCLUSIONS: In patients with native valve infective endocarditis: 1. The risk of early and late death is not related to the results of blood and valve cultures. 2. Staphylococcus aureus aetiology increases the risk of disease recurrence. 3. The risk of early death is significantly lower in patients treated with surgery.     

超声心动图诊断感染性心内膜炎的临床价值

目的探讨超声心动图在感染性心内膜炎诊断中的临床价值。方法应用超声心动图观察心脏瓣膜赘生物的形态、大小、回声、分布及其瓣膜损害情况及追踪患者在上级医院的诊疗结果并进行比较。结果超声心动图能直接提供心脏瓣膜赘生物的附着部位及数目、大小、形态、活动情况及相应的血流动力学变化。结论超声心动图能对感染性心内膜炎心脏瓣膜赘生物进行定性诊断,对临床制定治疗方案及预后判断有重要意义。