Antiphospholipid antibodies proposed in the diagnosis of infective endocarditis

Antiphospholipid antibodies (aPL) may occur alone or associated with other diseases. To evaluate aPL, tested as anticardiolipin antibodies (IgG aCL) in infective endocarditis (IE) diagnosis, we investigated their prevalence in a cohort of 651 patients with IE suspicion. aPL was significantly associated with definite IE versus IE-rejected patients. Their mean levels were significantly higher in patients with definite IE versus possible IE. When applied as Duke minor criterion, they were significantly more often positive, and at higher levels, in patients with definite IE than in patients with possible or rejected IE. aPL could be helpful in difficult cases of IE diagnosis.     

Staphylococcus aureus bacteraemia: evaluation of the role of transoesophageal echocardiography in identifying clinically unsuspected endocarditis

Staphylococcus aureus bacteraemia (SAB) is an important cause of community and nosocomial sepsis, with a significant mortality rate. Infective endocarditis (IE) is a serious complication, occurring in up to 25 % of cases. Transoesophageal echocardiography (TOE) significantly improves the sensitivity of diagnosis. We compared the sensitivity and specificity of clinical evaluation alone in diagnosing IE. We evaluated all adult patients with SAB at our centre from 1998 to 2006 in order to determine what proportion of clinically unsuspected cases were diagnosed with IE on TOE. IE was defined according to modified Duke criteria. The median age of the patients was 68 years, 77 % were male and the majority of cases did not have a known pre-existing condition. Twenty-one percent were methicillin-resistant Staphylococcus aureus (MRSA). Intravascular device was the most common cause of bacteraemia. TOE was performed in 144 (100 %) of the cases. IE was suspected clinically in 15 % of cases, and the overall prevalence of possible or definite IE on TOE-inclusive Duke criteria was 29 % (n?=?41). Following TOE, 22 (15 %) cases were reclassified as either possible or definite endocarditis. TOE detected a vegetation in 37 (90 %) of the 41 cases of IE. Nineteen (46 %) were not suspected clinically by Duke criteria. Sensitivity improved in the presence of pre-existing valve lesion or community acquisition. The overall in-hospital mortality was 10 %. There is a high incidence of endocarditis in SAB and a large percentage of cases are not evident on clinical grounds. TOE evaluation is indicated for all medically suitable adult patients with SAB in order to improve the detection of endocarditis.     

Contribution of systematic serological testing in diagnosis of infective endocarditis

Despite progress with diagnostic criteria, the type and timing of laboratory tests used to diagnose infective endocarditis (IE) have not been standardized. This is especially true with serological testing. Patients with suspected IE were evaluated by a standard diagnostic protocol. This protocol mandated an evaluation of the patients according to the modified Duke criteria and used a battery of laboratory investigations, including three sets of blood cultures and systematic serological testing for Coxiella burnetii, Bartonella spp., Aspergillus spp., Legionella pneumophila, and rheumatoid factor. In addition, cardiac valvular materials obtained at surgery were subjected to a comprehensive diagnostic evaluation, including PCR aimed at documenting the presence of fastidious organisms. The study included 1,998 suspected cases of IE seen over a 9-year period from April 1994 to December 2004 in Marseilles, France. They were evaluated prospectively. A total of 427 (21.4%) patients were diagnosed as having definite endocarditis. Possible endocarditis was diagnosed in 261 (13%) cases. The etiologic diagnosis was established in 397 (93%) cases by blood cultures, serological tests, and examination of the materials obtained from cardiac valves, respectively, in 348 (81.5%), 34 (8%), and 15 (3.5%) definite cases of IE. Concomitant infection with streptococci and C. burnetii was seen in two cases. The results of serological and rheumatoid factor evaluation reclassified 38 (8.9%) possible cases of IE as definite cases. Systematic serological testing improved the performance of the modified Duke criteria and was instrumental in establishing the etiologic diagnosis in 8% (34/427) cases of IE.     

Endocarditis: impact of methicillin-resistant Staphylococcus aureus in hemodialysis patients and community-acquired infection.

BACKGROUND AND PURPOSE: Staphylococcus aureus endocarditis showed an increase in the 1990s compared to the 1980s. In order to characterize the clinical and laboratory features of S. aureus endocarditis, we retrospectively reviewed the medical charts of patients diagnosed with endocarditis in the 5-year-period between 2000 and 2005. METHODS: From August 2000 to August 2005, 22 patients with a definite diagnosis of infective endocarditis (IE) caused by S. aureus were reviewed. RESULTS: Of the 22 patients reviewed, 16 cases were caused by methicillin-resistant S. aureus (MRSA) while the causative agent in the other 6 cases was methicillin-susceptible S. aureus (MSSA). Patients with MRSA infections were more likely to show hospital-acquired infections, hemodialysis and ventilator dependence, septic shock, impaired initial renal function, persistent bacteremia, and a higher 3-month mortality rate. MSSA infections in patients were more likely to be community-acquired, and show intravenous drug use and longer days of fever prior to admission. Three patients with MRSA endocarditis, however, presented community-acquired infections. The mortality rate of MRSA endocarditis in hemodialysis patients was 90% (9/10). CONCLUSIONS: MRSA IE is more common than MSSA IE and is associated with a significantly poorer prognosis, especially in patients undergoing hemodialysis. Although most cases of MRSA IE are hospital acquired, we noticed 3 cases of community-acquired MRSA IE. As MRSA IE has been noticed in the community and hemodialysis patients in recent years, and is associated with higher mortalities, strategies for its prevention and management are warranted.     

Infective endocarditis in Greece: a changing profile. Epidemiological, microbiological and therapeutic data

The epidemiology, and clinical and microbiological spectrum, of infective endocarditis (IE) in Greece was analysed in a prospective 4-year study in a tertiary hospital and a heart surgery centre in Athens. In total, 101 cases of IE (71 men, 30 women, aged 54.4 +/- 17.1 years) were studied, with a follow-up period of 3 months. Seventy-seven cases were definite and 24 possible; 59 involved native valves (native valve endocarditis; NVE), 31 prosthetic valves (prosthetic valve endocarditis; PVE), of which nine were early and 22 late, and 11 permanent pacemakers (pacemaker endocarditis; PME). There was a predominant involvement of aortic (48/101) and mitral (40/101) valves. Seven patients had rheumatic valvular disease, two had mitral valve prolapse, and eight had a previous history of IE. Thirteen and six patients had undergone dental and endoscopic procedures, respectively. In 13 patients, intravenous catheters were used within the 3 months before diagnosis of IE. There were three intravenous drug users among the patients. Staphylococcus aureus was the most important pathogen, isolated in 22% of cases, followed by viridans streptococci (19%) and coagulase-negative staphylococci (16%). Enterococcus spp. were responsible for 3%, HACEK group for 2%, and fungi for 6% of cases. Viridans streptococci were the leading cause of NVE (29%), Staphylococcus epidermidis of PVE (16%), and S. aureus of PME (54.5%). Six of 22 S. aureus and ten of 16 S. epidermidis isolates were methicillin-resistant. Surgical intervention, including total pacemaker removal, was performed in 51.5% of patients. Overall mortality was 16%, but was 29% with PVE, and was significantly higher with medical than with combined surgical and medical therapy (24.5% vs. 8%). Compared with previous studies, there were changing trends in the epidemiology, microbiology, treatment and prognosis of IE in Greece.     

Clinical and Laboratory Characteristics of Infective Endocarditis When Associated with Spondylodiscitis

Spondylodiscitis is rarely observed in association with infective endocarditis (IE). In the study presented here, 92 cases of definite IE were examined. Spondylodiscitis was present in 14 (15%) cases. The mean age of patients with spondylodiscitis was 69.1±13.6 years (range, 33–87 years). The male-to-female ratio was 8:6. Predisposing heart disease was found in nine (64.3%) cases. Back pain was reported in all cases. Spondylodiscitis was diagnosed before endocarditis in all cases. The infection affected the lumbar spine in 10 (71%) cases. A bacterium was isolated in all cases: group D Streptococcus (n=5; 35.7%), coagulase-negative Staphylococcus (n=4; 28.6%), and others (n=5). Endocarditis affected predominantly the aortic valve (43%). The outcome was favourable in 12 cases. No differences in clinical features, evolution of disease, or laboratory values were found between IE patients with and IE patients without spondylodiscitis. Spondylodiscitis does not appear to worsen prognosis of IE, although the need for cardiac valve replacement seems to be more frequent in IE patients with spondylodiscitis. IE should be included in the differential diagnosis in patients with infectious spondylodiscitis and risk factors for endocarditis. In such patients, echocardiography should be performed routinely. Electronic Publication     

Western immunoblotting for Bartonella endocarditis

To differentiate infectious endocarditis (IE) from other Bartonella infections and to identify infecting Bartonella bacteria at the species level on a serological basis, we used Western immunoblotting to test sera from 51 patients with Bartonella IE (of which 27 had previously benefited from species identification by molecular techniques), 11 patients with chronic Bartonella quintana bacteremia, and 10 patients with cat scratch disease. Patients with IE were Western blot positive in 49 of 51 cases, and significant cross-reactivity with three heterologous Bartonella antigens was found in 45 of 49 cases. Sera from bacteremic patients did not react with more than one heterologous antigen, and sera from patients with cat scratch disease gave negative results. Sera reacted only with B. henselae in four cases of IE, including one with a positive PCR result for valve tissue. Western blot and cross-adsorption performed on serum samples from patients with IE (the identity of the causative species having been determined by PCR) were demonstrated to identify efficiently the causative species in all cases. When applied to patients diagnosed on the basis of serological tests only, this technique allowed identification of the causative species in 20 of 22 cases. The results were in accordance with epidemiological features. Six reactive bands of B. quintana (of molecular sizes from 10 to 83 kDa) demonstrated significant association with sera from patients with B. quintana endocarditis. Overall, Western blotting and cross-adsorption made it possible to identify the causative species in 49 of 51 (96%) IE cases.     

Is brain angio-MRI useful in infective endocarditis management?

In infective endocarditis (IE), brain magnetic resonance imaging (MRI) is helpful to diagnose clinically silent neurological events. We assessed the usefulness of systematic early brain MRI in IE diagnosis and medico-surgical management. Over a period of 1 year, all patients admitted in one of the three hospitals participating in and fulfilling the Duke criteria for definite or possible IE underwent cerebral MRI within 7 days of IE suspicion. Eight panels of experts analyzed the records a posteriori. For each case, one record with and one record without the MRI results were randomly assigned to two panels, which determined the theoretical diagnosis and treatment. Paired comparisons were performed using a symmetry test. Thirty-seven brain MRIs were performed within a median of 5 days after inclusion. MRI was pathological in 26 patients (70 %), showing 62 % microischemia and 58 % microbleeds. The expert advice did not differ significantly between the two evaluations (with or without the MRI results). The therapeutic strategies determined diverged in five cases (13.5 %). Diagnosis differed in two cases (5.4 %), with an upgrading of diagnosis from possible to definite IE using MRI results. Early brain MRI did not significantly affect the IE diagnosis and medico-surgical treatment plan. These results suggest that systematic use of early brain MRI is irrelevant in IE. Further studies are necessary to define whether MRI is mandatory in IE management within a multidisciplinary approach, with particular attention paid to better timing and the subset of patients in whom this imaging examination could be beneficial.     

Value of PCR in surgically treated patients with staphylococcal infective endocarditis: a 4-year retrospective study

The aim of the study was to establish a diagnostic value for broad-range polymerase chain reaction (br-PCR) and staphylococci-specific multiplex PCR (ssm-PCR) performed on surgical material from patients with staphylococcal infective endocarditis (IE). Data were analysed retrospectively from 60 patients with suspected staphylococcal IE and 59 controls who were surgically treated at three cardiosurgery centres over 4 years. Both PCR tests showed high agreement and could be aggregated. In patients with definite and rejected IE, the clinical sensitivity and specificity of PCR reached 89 and 95%, respectively. Tissue culture (TC) and PCR agreed with blood culture (BC) in 29% and 67% of IE cases. TC helped to determine aetiology in five BC negative cases while PCR aided in nine cases. Out of 52 patients with conclusive staphylococcal IE, 40 were diagnosed with S. aureus and 12 with coagulase-negative staphylococci. PCR was shown to be highly superior to TC in confirming preoperative diagnosis of IE. In addition to aid in culture negative patients, PCR helped to establish or refine aetiology in inconclusive cases. We suggest that simultaneous br-PCR and ssm-PCR performed on surgical material together with histopathology could significantly increase the performance of current Duke criteria.     

Heart valves should not be routinely cultured

Heart valve (HV) culture is one of the major Duke criteria for the diagnosis of definite infectious endocarditis (IE). However, previous series suggest that heart valve culture does not have good sensitivity (7.8 to 17.6%) and may be contaminated during manipulation. Our goal was to establish the value of routine cultures of heart valves in patients with and without IE. From 2004 to 2006, resected heart valves were systematically cultured according to standard procedures. The definition and etiology of IE were based on the Duke criteria and on valve PCR of specimens from blood culture-negative patients. Bacterial and fungal broad-range PCR was performed. A total of 1,101 heart valves were studied: 1,030 (93.6%) from patients without IE and 71 (6.4%) from patients with IE (42 patients). Overall, 321 (29.2%) cultures were positive (28/71 [39.4%] IE cases and 293/1,030 [28.4%] non-IE). All IE patients with negative heart valve cultures had received antimicrobial therapy. The yield of culture of heart valves for IE diagnosis was as follows: sensitivity, 25.4%; specificity, 71.6%; positive predictive value (PPV), 5.8%; and negative predictive value, 93.3%. Because of its poor sensitivity and PPV, valve cultures should not be performed for patients without a clinical suspicion of IE. For patients with confirmed IE, heart valve cultures should be interpreted with caution.     

Staphylococcus aureus bacteraemia,cardiac implantable electronic device,and the risk of endocarditis: a retrospective population–based cohort study

Patients with cardiac implantable electronic device (CIED) and Staphylococcus aureus bacteraemia (SAB) are at risk of having infective endocarditis (IE). The objectives were to describe a Swedish population-based cohort of patients with CIED and SAB, to identify risk factors, and to construct a predictive score for IE. Patients over 18 years old in the Stockholm Region identified to have SAB in the Karolinska Laboratory database from January 2015 through December 2019 were matched to the Swedish Pacemaker and Implantable Cardioverter-Defibrillator ICD Registry to identify the study cohort. Data were collected from study of medical records. A cohort of 274 patients with CIED and SAB was identified and in 38 episodes (14%) IE were diagnosed, 19 with changes on the CIED, and 35 with changes on the left side of the heart. The risk factors predisposition for IE, community acquisition, embolization, time to positivity of blood cultures, and growth in blood culture after start of therapy in blood cultures were independently associated to IE. A score to identify patients with IE was constructed, the CTEPP score, and the chosen cut-off generated a sensitivity of 97%, specificity of 25%, and a negative predictive value of 98%. The score was externally validated in a population-based cohort of patients with CIED and SAB from another Swedish region. We found that 14% of patients with CIED and SAB had definite IE diagnosed. The CTEPP-score can be used to predict the risk of IE and, when negative, the risk is negligible.

     

Western Immunoblotting for Bartonella Endocarditis

To differentiate infectious endocarditis (IE) from other Bartonella infections and to identify infecting Bartonella bacteria at the species level on a serological basis, we used Western immunoblotting to test sera from 51 patients with Bartonella IE (of which 27 had previously benefited from species identification by molecular techniques), 11 patients with chronic Bartonella quintana bacteremia, and 10 patients with cat scratch disease. Patients with IE were Western blot positive in 49 of 51 cases, and significant cross-reactivity with three heterologous Bartonella antigens was found in 45 of 49 cases. Sera from bacteremic patients did not react with more than one heterologous antigen, and sera from patients with cat scratch disease gave negative results. Sera reacted only with B. henselae in four cases of IE, including one with a positive PCR result for valve tissue. Western blot and cross-adsorption performed on serum samples from patients with IE (the identity of the causative species having been determined by PCR) were demonstrated to identify efficiently the causative species in all cases. When applied to patients diagnosed on the basis of serological tests only, this technique allowed identification of the causative species in 20 of 22 cases. The results were in accordance with epidemiological features. Six reactive bands of B. quintana (of molecular sizes from 10 to 83 kDa) demonstrated significant association with sera from patients with B. quintana endocarditis. Overall, Western blotting and cross-adsorption made it possible to identify the causative species in 49 of 51 (96%) IE cases.     

Enterococcal endocarditis in the beginning of the 21st century: analysis from the International Collaboration on Endocarditis-Prospective Cohort Study

Enterococci are reportedly the third most common group of endocarditis-causing pathogens but data on enterococcal infective endocarditis (IE) are limited. The aim of this study was to analyse the characteristics and prognostic factors of enterococcal IE within the International Collaboration on Endocarditis. In this multicentre, prospective observational cohort study of 4974 adults with definite IE recorded from June 2000 to September 2006, 500 patients had enterococcal IE. Their characteristics were described and compared with those of oral and group D streptococcal IE. Prognostic factors for enterococcal IE were analysed using multivariable Cox regression models. The patients’ mean age was 65 years and 361/500 were male. Twenty-three per cent (117/500) of cases were healthcare related. Enterococcal IE were more frequent than oral and group Dstreptococcal IE in North America. The 1-year mortality rate was 28.9% (144/500). E. faecalis accounted for 90% (453/500) of enterococcal IE. Resistance to vancomycin was observed in 12 strains, eight of which were observed in North America, where they accounted for 10% (8/79) of enterococcal strains, and was more frequent in E. faecium than in E. faecalis (3/16 vs. 7/364, p 0.01). Variables significantly associated with 1-year mortality were heart failure (HR 2.4, 95% CI 1.7—3.5, p <0.0001), stroke (HR 1.9, 95% CI 1.3—2.8, p 0.001) and age (HR 1.02 per 1-year increment, 95% CI 1.01—1.04, p 0.002). Surgery was not associated with better outcome. Enterococci are an important cause of IE, with a high mortality rate. Healthcare association and vancomycin resistance are common in particular in North America.     

Chronic antiplatelet therapy and mortality among patients with infective endocarditis

Whether antiplatelet therapy is associated with better outcomes among patients with infective endocarditis (IE) remains controversial. A retrospective study was conducted concerning all patients with IE, treated in a tertiary-care centre of Canada between 1991 and 2006, who satisfied the modified Duke criteria for a definite or possible IE. The primary outcome was all-cause mortality within 90 days of diagnosis. A secondary outcome was the development of major systemic embolism. In total, 241 patients satisfied the inclusion criteria, 75 of whom had been on chronic antiplatelet therapy prior to developing endocarditis. Seventy-one (29.5%) patients died. According to multivariate analysis, age, a high Charlson score, aortic valve involvement, myocardial infarction and presence of a perivalvular abscess were strongly associated with mortality. Undergoing valvular replacement (adjusted OR (AOR) 0.28, 95% CI  0.09–0.84) and chronic antiplatelet therapy before IE (AOR  0.27, 95% CI  0.11–0.64) correlated with lower mortality. There was a trend for lower mortality among patients started on antiplatelet drugs after admission (AOR  0.29, 95% CI  0.08–1.13). The effect of aspirin on mortality was much the same in patients who received 325 or 80 mg daily. Chronic antiplatelet therapy was not associated with a significantly lower risk of major embolism. In conclusion, chronic antiplatelet therapy was associated with lower mortality among patients with IE, independently of any effect on major embolism. Whether or not a beneficial effect could be replicated by initiating antiplatelet therapy at the time of diagnosis remains unproven.     

Outpatient treatment of endocarditis in a clinic-based program in Argentina

The major cost in the treatment of infective endocarditis (IE) is the length of hospitalization required for the administration of intravenous antibiotics. This can be reduced by substituting shorter regimens and by the introduction of outpatient parenteral antibiotic therapy (OPAT). Careful selection of patients is vital for the success of OPAT in IE. The patients should be hemodynamically stable and without clinical complications. The delivery of OPAT for IE followed a clinical and home-based program involving an endocarditis team whose members included an infectious diseases physician, a microbiologist, a cardiologist and a nurse trained in intravenous techniques. Among the antimicrobial agents used in OPAT of IE, single-agent ceftriaxone for four weeks followed by a short course of amoxicillin or ceftriaxone in combination with an aminoglycoside for two weeks (short course) are effective modes of treatment for streptococcal endocarditis, the most common cause of IE. This treatment is also effective for carefully selected patients with other types of endocarditis, such as those due to the HACEK group (Haemophilus aphrophilus/paraphrophilis, Actinobacillus actinomycetem comitans, Cardiobacterium hominis, Eikenella corrodens andKingella kingae).Staphylococcus aureus, enterococci and late prosthetic valve endocarditis associated with a streptococcus may also be treated on an outpatient basis after stabilization (approximately 2 weeks). As a result of their need for prolonged treatment periods, these patients are also very good candidates for OPAT. In conclusion, new regimens utilizing ceftriaxone once daily and short-term therapy on a clinical or home basis offer the potential benefits of cheaper, safer and more convenient treatment for patients with IE.     

Simplified risk stratification criteria for identification of patients with MRSA bacteremia at low risk of infective endocarditis: implications for avoiding routine transesophageal echocardiography in MRSA bacteremia

The aim of this study was to identify patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with low risk of infective endocarditis (IE) who might not require routine trans-esophageal echocardiography (TEE). We retrospectively evaluated 398 patients presenting with MRSA bacteremia for the presence of the following clinical criteria: intravenous drug abuse (IVDA), long-term catheter, prolonged bacteremia, intra-cardiac device, prosthetic valve, hemodialysis dependency, vertebral/nonvertebral osteomyelitis, cardio-structural abnormality. IE was diagnosed using the modified Duke criteria. Of 398 patients with MRSA bacteremia, 26.4 % of cases were community-acquired, 56.3 % were health-care-associated, and 17.3 % were hospital-acquired. Of the group, 44 patients had definite IE, 119 had possible IE, and 235 had a rejected diagnosis. Out of 398 patients, 231 were evaluated with transthoracic echocardiography (TTE) or TEE. All 44 patients with definite IE fulfilled at least one criterion (sensitivity 100 %). Finally, a receiver operator characteristic (ROC) curve was obtained to evaluate the total risk score of our proposed criteria as a predictor of the presence of IE, and this was compared to the ROC curve of a previously proposed criteria. The area under the ROC curve for our criteria was 0.710, while the area under the ROC curve for the criteria previously proposed was 0.537 (p?<?0.001). The p-value for comparing those 2 areas was less than 0.001, indicating statistical significance. Patients with MRSA bacteremia without any of our proposed clinical criteria have very low risk of developing IE and may not require routine TEE.     

Serum procalcitonin has the potential to identify <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> endocarditis

The role of procalcitonin (PCT) in the diagnosis of infective endocarditis (IE) remains unclear. The aim of our study was to test the accuracy of PCT in the early diagnosis of IE and analyse if the accuracy of PCT is dependent on the type of pathogen causing IE. We carried out a prospective analysis of hospitalised patients referred for transthoracic echocardiography to search for an IE. The plasma PCT value was measured at the time of echocardiography. The diagnosis of IE was made using the modified Duke criteria. A total of 77 patients were included. IE was confirmed in 15 patients. The mean PCT values were 6.9 (±21.6) ug/l in patients without IE and 6.4 (±11.7) ug/l in patients with confirmed IE (p=0.92). IE patients with Staphylococcus aureus bacteraemia (n=7) had significantly higher PCT values compared to IE patients with other types of bacteraemia (n=8) (13.1 vs. 0.435, p=0.0299). This study demonstrates that PCT levels markedly differ at the time when IE is diagnosed. While PCT values are very high in patients with S. aureus bacteraemia, they are surprisingly low in patients with Streptococcus viridans bacteraemia, which are common offenders of endocarditis. We conclude that serum PCT has the potential to be used in the early diagnosis of S. aureus endocarditis.     

Definite Streptococcus bovis endocarditis: characteristics in 20 patients

Objective   To determine the specific characteristics of Streptococcus bovis infective endocarditis (IE) by reviewing our own experience of S. bovis IE.
Methods   Twenty episodes of definite S. bovis IE were reviewed in 20 patients hospitalized from 1980 to 1996.
Results   The mean age was 62 ± 14 years, and 14 (70%) patients had no known predisposing cardiac condition. The principal antimicrobials used were penicillin G ( N  = 10) and amoxycillin ( N  = 8). Surgery was required in four (20%) patients. Neurologic complications occurred in eight (40%) patients, after initiation of therapy in six (75%) (mean time: 14 days). An unfavorable outcome was observed in four of 20 patients and tended to be more frequent in patients who had had neurologic complications ( P  = 0.10). Colonic tumors were present in 11 of 16 (69%) patients.
Conclusions   Advanced age, occurrence of IE on presumably normal valves, high rate of neurologic complications, associated gastrointestinal diseases and low mortality rate during initial follow-up are characteristic features of S. bovis IE observed in this study.     

Repeat endocarditis: analysis of risk factors based on the International Collaboration on Endocarditis – Prospective Cohort Study

Repeat episodes of infective endocarditis (IE) can occur in patients who survive an initial episode. We analysed risk factors and 1-year mortality of patients with repeat IE. We considered 1874 patients enrolled in the International Collaboration on Endocarditis – Prospective Cohort Study between January 2000 and December 2006 (ICE-PCS) who had definite native or prosthetic valve IE and 1-year follow-up. Multivariable analysis was used to determine risk factors for repeat IE and 1-year mortality. Of 1874 patients, 1783 (95.2%) had single-episode IE and 91 (4.8%) had repeat IE: 74/91 (81%) with new infection and 17/91 (19%) with presumed relapse. On bivariate analysis, repeat IE was associated with haemodialysis (p 0.002), HIV (p 0.009), injection drug use (IDU) (p < 0.001), Staphylococcus aureus IE (p 0.003), healthcare acquisition (p 0.006) and previous IE before ICE enrolment (p 0.001). On adjusted analysis, independent risk factors were haemodialysis (OR, 2.5; 95% CI, 1.2–5.3), IDU (OR, 2.9; 95% CI, 1.6–5.4), previous IE (OR, 2.8; 95% CI, 1.5–5.1) and living in the North American region (OR, 1.9; 95% CI, 1.1–3.4). Patients with repeat IE had higher 1-year mortality than those with single-episode IE (p 0.003). Repeat IE is associated with IDU, previous IE and haemodialysis. Clinicians should be aware of these risk factors in order to recognize patients who are at risk of repeat IE.     

Characteristics and regional variations of group D streptococcal endocarditis in France

The proportion of infective endocarditis (IE) caused by group D streptococci (GDS; formerly Streptococcus bovis) increased markedly in France, to account for 25% of all cases of IE by 1999. In an attempt to explain this phenomenon, a comparative analysis of GDS and oral streptococci (OS) causing IE was performed. This study was based on data collected from a large cross-sectional population-based survey that was conducted in 1999. In total, 559 cases of definite IE were recorded, of which 142 involved GDS and 79 involved OS. Patients with GDS IE were older (62.7 vs. 56.6 years, p 0.01) and had a history of valve disease less frequently than did patients with OS IE (33.8% vs. 67.1%, p <0.0001). At-risk procedures for IE were performed less frequently in patients with GDS than in patients with OS (14.8% vs. 24.1%, p 0.08), but co-morbidities were more frequent in the GDS group (59.9% vs. 32.9%, p 0.0001). Diabetes, colon diseases and cirrhosis were also more frequent in the GDS group (p 0.006, p <0.0001 and p 0.08, respectively). Rural residents accounted for 31.0% of the GDS group, but for only 15.2% of the OS group (p 0.001). Likewise, the proportion of GDS IE was higher in regions with mixed (urban and rural) populations (Franche-Comté 81.8%, Marne 68.7%, Lorraine 70.3% and Rhône-Alpes 65.3%) than in exclusively urban regions (Paris and Ile de France 58.0%). Further investigations are required to elucidate the link in France between the incidence of GDS IE, rural residency and nutritional factors.