Can transthoracic echocardiography be used to a greater extent in the diagnostics of infective endocarditis to avoid unnecessary transoesophageal examinations without jeopardising accuracy?

BACKGROUND: Infective endocarditis (IE) is a serious condition that requires prompt diagnosis and treatment. Transthoracic echocardiography (TTE) is usually the initial imaging modality, however transoesophageal echocardiography (TOE) is sometimes necessary because of its higher sensitivity for IE. Yet, TOE may imply an increased risk of complications. This project aims to evaluate whether TTE can be used to a greater extent in the diagnostics of IE to avoid unnecessary TOE examinations without jeopardizing diagnostic accuracy. METHODS: Data from all TOE examinations performed on patients hospitalized with clinical suspicion of IE between 2019-05-01 and 2020-04-30 at a university hospital in Stockholm, Sweden, were obtained and analysed. Variables included for analysis were age, sex, blood culture results, aetiology, results from TOE, number of TOEs during the inclusion period, results from positron emission tomography/computed tomography (PET/CT), new regurgitation, cardiac murmur, previous IE, prosthetic valve, predisposing factors, i.e. cardiac comorbidities, injection drug use, fever, vascular phenomena, and immunological phenomena. To assess associations between predisposing factors or aetiology of IE and TOE findings, chi square tests and logistic regression models were used. For continuous variables, linear regression was used for comparisons of means and quantile regression was used for comparisons of medians. P < 0.05 was considered significant. RESULTS: In total 195 TOE examinations (Table 1) from 160 patients were included, of which 61 (31%) were positive for IE. In total, 36 examinations had negative TTE prior to TOE of which 32 (86%) also had negative TOE. Of the 5 (14%) negative TTE prior to TOE that had positive TOE, all had cardiovascular implantable electronic device (CIED) and/or prosthetic valves. CONCLUSIONS: The existing recommendations for TOE in patients with clinical suspicion of IE are probably broad enough not to miss patients with IE, but there might be an unnecessarily large number of patients being referred for TOE with negative results. Negative TTE examination with good image quality and no CIED or prosthetic valves, may be sufficient without jeopardizing the IE diagnosis.

Patients with infective endocarditis and history of injection drug use in a Swedish referral hospital during 10 years.

BACKGROUND: Patients with injection drug use (IDU) have increased risk of developing infective endocarditis (IE). Previous studies have reported recurrent IE, increased duration of hospital stay, poor adherence and compliance as well as higher mortality and worse outcomes after surgery in the IDU-IE patient group. Further studies are needed to provide a basis for optimized care and prevention of readmissions in this population. This study aims to describe the clinical characteristics and outcomes among patients with IDU-IE. METHODS: Data of adults with IDU-IE and non-IDU-IE, treated between 2008 and 2017 at the Karolinska University Hospital in Stockholm were obtained from the Swedish National Registry of Infective Endocarditis. Clinical characteristics, microbiological results, treatment durations, results from echocardiography and in-hospital mortality were compared between the groups. RESULTS: Of the total 522 patients, 165 (32%) had IDU-IE. Patients with IDU-IE were younger than the patients with non-IDU-IE (mean age IDU-IE: 41.6 years, SD 11.9 years; non-IDU-IE: 64.3 years, SD 16.4 years; P <  0.01). No difference in distribution of gender was observed, 33% were females in both the IDU-IE and the non-IDU-IE group. History of previous IE (IDU-IE: n = 49, 30%; non-IDU-IE: n = 34, 10%; P <  0.01) and vascular phenomena (IDU-IE: n = 101, 61%; non-IDU-IE: n = 120, 34%; P <  0.01) were more common among patients with IDU-IE while prosthetic heart valves (IDU-IE: n = 12, 7%; non-IDU-IE: n = 83, 23%; P <  0.01) and known valvular disease (IDU-IE: n = 3, 2%; non-IDU-IE: n = 78, 22%; P <  0.01) were more common among patients with non-IDU-IE. Aetiology of Staphylococcus aureus (IDU-IE: n = 123, 75%; non-IDU-IE: n = 118, 33%; P <  0.01) as well as tricuspid (IDU-IE: n = 91, 55%; non-IDU-IE: n = 23, 6%; P <  0.01) or pulmonary valve vegetations (IDU-IE: n = 7, 4%; non-IDU-IE: n = 2, 1%; P <  0.01) were more common in the IDU-IE group. The overall incidence of IDU-IE decreased during the study period, while the incidence of definite IE increased (P <  0.01). CONCLUSIONS: This study presents that patients with IDU-IE were younger, less frequently treated with surgery and had higher prevalence of vascular phenomena and history of previous IE, aspects that are important for improved management of this population.

Antibiotic prescribing among patients with severe infectious diseases in two private sector hospitals in Central India - a time series analysis over 10 years.

BACKGROUND: Antibiotic resistance is an emerging problem caused due to antibiotic use. In countries with high rates of infectious diseases, antibiotic resistance is a frequent cause of mortality. The aim was to analyse antibiotic prescribing practices between 2008 and 2017 in a teaching (TH) and a non-teaching (NTH) hospital, as typical hospitals of low- and middle-income countries, and to compare antibiotic prescribing for severe infectious indications for which empiric antibiotic treatment is recommended. METHODS: Data from adult patients registered at two Indian private-sector hospitals with one of the following indications: epiglottitis, pneumonia, peritonitis, pyelonephritis, cellulitis, erysipelas, septic arthritis, endocarditis, meningitis or sepsis; were included and analysed. Antibiotic prescription data was analyzed using the World Health Organization's (WHO) Anatomical Therapeutic Chemical classification system and the Defined Daily Doses. Chi-square and linear regression were used to compare the data between groups. Time series analyses were conducted using linear regression. P-values < 0.05 were considered significant. RESULTS: In total, 3766 patients were included, 2504 inpatients in the NTH and 1262 in the TH, of which 92 and 89% patients, respectively, were prescribed antibiotics. Sixty-one percent of total prescriptions in the TH and 40% in the NTH comprised the access category of antibiotics (i.e. the first-choice of treatment according to the WHO). The WHO's second-choice of treatment, the watch category, comprised 29 and 40% of total prescriptions in the TH and NTH, respectively. Prescribing of fixed-dose combinations (FDCs) of antibiotics was significantly higher in the NTH (18%) than in the TH (8%, P < 0.05). Prescribing of watch antibiotics and FDCs increased significantly in both hospitals between 2008 and 2017 among patients with pneumonia, cellulitis and peritonitis (P < 0.05). CONCLUSIONS: Prescribing of watch antibiotics and FDCs of antibiotics increased over time at both hospitals, indicating under prescribing of access antibiotics and more prescribing of second-choice antibiotics. The results can be used to highlight the areas of improvement in similar settings. Implementing diagnostic routines and local prescribing guidelines could improve the prescribing practices.

Mind the Gap in TAVR: Recognizing and Managing Misloaded Self-Expanding TAVR Devices.

Misloading during transcatheter aortic valve replacement (TAVR) is rare but can cause unpredictable valve release if unrecognized. We describe how to identify a misloaded ACURATE neo2 device, and 3 methods to solve this by using a modified technique of valve deployment, ipsilateral extraction, and contralateral valve externalization with extracorporeal valve release.

Alcohol septal ablation for hypertrophic obstructive cardiomyopathy: do mitral valve leaflet length, septal thickness, or sex affect the outcome?

This retrospective cohort study aimed to assess whether basal septal wall thickness (BSWT), anterior (AML) and posterior (PML) mitral leaflet length, or sex were associated with remaining left ventricular outflow tract obstruction (LVOTO) in patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing alcohol septal ablation (ASA). One hundred fifty-four patients who underwent ASA at the Karolinska University Hospital in Stockholm, Sweden, between 2009 and 2021, were included retrospectively. Anatomical and hemodynamic parameters were collected from invasive catheterization before and during ASA, and from echocardiography (ECHO) examinations before, during, and at 1-year follow-up after ASA. Linear and logistic regression models were used to assess the association between sex, BSWT, AML, PML, and outcome, which was defined as the remaining LVOTO (≥ 30 mmHg) after ASA. The median follow-up was 364 days (interquartile range 334-385 days). BSWT ≥ 23 mm (n = 13, 12%) was associated with remaining LVOTO at follow-up (p = 0.004). Elongated mitral valve leaflet length (either AML or PML) was present in 125 (90%) patients. Elongated AML (> 24 mm) was present in 67 (44%) patients, although AML length was not associated with remaining LVOTO at follow-up. Elongated PML (> 14 mm) was present in 114 (74%) patients and was not associated with remaining LVOTO at follow-up. No significant sex differences were observed regarding the remaining LVOTO. ECHO measurement of BSWT can be effectively used to select patients for successful ASA and identify those patients with a risk of incomplete resolution of LVOTO after ASA.

BASILICA Procedure Prior to Valve-in-Valve TAVR in a Supra-Annular TAV Prosthesis.

An 80-year-old man with a supra-annular transcatheter aortic valve (TAV) prosthesis presented with severe transvalvular aortic regurgitation 18 months after the TAV replacement procedure. The authors report the first ever valve-in-valve procedure using BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) in such a supra-annular TAV prosthesis. Minimal paravalvular leakage, normal coronary artery flow, and easy coronary access were seen postimplantation. (Level of Difficulty: Advanced.).

Antibiotic Prescribing among Pediatric Inpatients with Potential Infections in Two Private Sector Hospitals in Central India.

INTRODUCTION: Infectious diseases are one of the major causes of child mortality in India. Pediatric patients are commonly prescribed antibiotics for non-bacterial infections. Monitoring of local antibiotic prescribing with respect to the diagnosis is necessary to improve the prescribing practices. The aim of the study was to describe antibiotic prescribing for potential infections among patients admitted in pediatric departments in two private sector hospitals; one teaching (TH) and one non-teaching (NTH) in Central India. METHODS: Data from all patients admitted at the pediatric departments of both study hospitals was collected manually, for 3 years (2008-2011) using a customized form. Data from inpatients aged 0-18 years, diagnosed with; acute gastroenteritis (AGE), respiratory tract infections, enteric fever, viral fever or unspecified fever were focused for analysis. Antibiotic prescriptions were analysed using the WHO Anatomical Therapeutic Chemical (ATC) classification system and defined daily doses (DDDs). Adherence to the Indian Academy of Pediatrics list of essential medicines (IAP-LEM) was investigated. P-values <0.05 were considered significant. RESULTS: Oftotal6, 825 inpatients admitted at two pediatric departments, 510 patients from the TH and 2,479from the NTH were selected based on the assigned potential infectious diagnoses. Of these, 224 patients (44%) at the TH and 2,088 (84%) at the NTH were prescribed at least one antibiotic during hospital stay (odds ratio-0.69, 95%confidence interval-0.52 to 0.93; p<0.001). Patients with AGE, viral- and enteric fever were frequently prescribed antibiotics at both hospitals, yet higher proportion were prescribed antibiotics at the NTH compared to the TH. Broad-spectrum antibiotics were the most commonly prescribed antibiotic class in both hospitals, namely third generation cephalosporins, J01DD (69%) at the TH, and new fixed dose combinations of antibiotics J01R (FDCs, 42%) at the NTH. At the TH, 37% of the antibiotic prescriptions were comprised of antibiotics listed in the IAP-LEM, compared to 24% at the NTH (p<0.05). CONCLUSIONS: Broad-spectrum antibiotics were prescribed frequently in both hospitals also for the un-indicated conditions such as viral fever and enteric fever. At the NTH, new FDCs were more frequently prescribed and adherence to the IAP-LEM was substantially lower at the NTH compared to the TH. The results demonstrate need to develop diagnosis-specific prescribing guidelines to facilitate rational use of antibiotics and implement antibiotic stewardship program.

Antibiotic prescribing in medical intensive care units--a comparison between two private sector hospitals in Central India.

BACKGROUND: Inappropriate antibiotic prescribing, common in India, contributes to increased risk for development of bacterial resistance. Patients admitted to intensive care units (ICUs) are often prescribed antibiotics. Paucity of local data on antibiotic prescribing hinders development of appropriate interventions. The aim of the study was to describe and compare antibiotic prescribing in medical ICUs (MICUs) at two private sector hospitals, one teaching (TH) and one non-teaching (NTH) in Ujjain, India. METHODS: The study was conducted prospectively for 3 years at MICUs of both hospitals. Patients were compared for demographic variables and diagnosis, prescribed antibiotics, generic name prescribing, and route of administration. Adherence to the World Health Organization list of essential medicines (WHOLEM) and the National List of Essential Medicines of India (NLEMI) was analyzed. RESULTS: In total, 4843 of 6141 patients admitted to the MICUs stayed at least one night. More than 70% were prescribed antibiotics. Generic name prescribing was more common at the TH than at the NTH. Prescriptions at the TH had higher compliance to WHOLEM and NLEMI compared with that at the NTH (p < 0.001). Of the 1371 patients at the TH, 189 (14%) and of 3472 at the NTH, 400 (12%) patients were diagnosed with infections. More than 75% of patients at both hospitals had no infection-associated diagnoses. CONCLUSIONS: Antibiotic prescribing was common at both hospitals. The antibiotic prescriptions at the TH had higher compliance to WHOLEM and NLEMI. However, there is a need to develop appropriate interventions to improve antibiotic prescribing at both hospitals.