Candida spp. infective endocarditis: Characteristics and outcomes of twenty patients with a focus on injection drug use as a predisposing risk factor.

BACKGROUND: Candida spp. infective endocarditis (CIE) although rare is associated with high morbidity and mortality. Risk factors include prosthetic heart valves and injection drug use (IDU). We reviewed all cases of CIE at our institution to describe the microbiology, treatment and outcomes of patients focusing on IDU as a predisposing factor. METHODS: Retrospective cohort of patients with definite CIE between 2013 and 2019 at a university hospital was analysed. Demographic data collected included IDU, microbiologic, treatment and mortality. The primary outcome of interest was 12-month, all-cause mortality. RESULTS: Twenty patients were included (one had two separate episodes of CIE); CIE accounted for 4% of total infective endocarditis (IE) cases during the study period. The median (IQR) age was 38 (30-58) years, 10 (50%) had a previous history of IE, and 4 (20%) patients had prosthetic heart valves or an implanted cardiac device. Thirteen (65%) patients were IDU. The tricuspid valve was the primary valve involved (8/18, 44%), and C albicans was the most frequently isolated organism (8, 36%). Echinocandin was the most common treatment strategy (8, 40%). Only three (15%) patients underwent valve replacement during hospitalisation. There were no in-hospital fatalities, and 5 (25%) patients died at one year; all were IDU (39% to 0%, p = .11). CONCLUSION: CIE is a rare infectious disease seen more commonly in the IDU population. Cardiac surgery was rarely performed, and long-term mortality was 25%. Additional data are needed to identify ideal management strategies in this population.

Elevated troponin level as a predictor of inpatient mortality in patients with infective endocarditis in the Southeast United States.

BACKGROUND: Despite recent improvement in management, infective endocarditis (IE) continues to be associated with considerable risk of morbidity and mortality. Early identification of predictors of inpatient mortality is key in improving patient outcomes in IE. The aim of our study was to evaluate the role of serum troponin levels measurements as a marker of increased mortality. METHODS: A case-control study included adult patients with IE admitted to a tertiary care hospital in east Tennessee between December 2012 and July 2017. Cases were defined as patients with definitive IE who died in-hospital; controls were patients who did not die in hospital. First patient admission was included only. Data collected included the patients' demographic and baseline clinical information, microbiological data, injection drug use status, elevated serum troponins levels. RESULTS: Two hundred eighty three patients with definitive IE were included; median (IQR) age was 41 (30-57) years, and 153 (54%) patients were men. One-hundred sixty-four (58%) were injection drug users. The most frequent IE type was: 167 (59%) right-sided, 86 (30%) left-sided, 24 (9%) both left and right-sided, and 10 (4%) device related. The most commonly isolated organism was Staphylococcus aureus (n = 141), and 64% were methicillin-resistant. Two-hundred twelve (75%) patients had a troponin level obtained, and 57 (27%) had an elevated troponin value. Thirty-six (13%) patients died in-hospital; in-hospital mortality was associated elevated troponin values (adjusted odds ratio [adjOR], 7.3; 95%CI, 3.3-15.9), and methicillin-resistant S. aureus IE (adjOR 2.6; 95%CI, 1.2-5.8). Forty-four (16%) patients received IE valve surgery, and none of these patients died in the hospital. CONCLUSION: Inpatient mortality was higher in patients with IE and elevated cardiac troponin levels compared to patients with normal levels.

Use of an antimicrobial pouch/envelope in the treatment of Twiddler's syndrome.

BACKGROUND: "Twiddler's syndrome" occurs when a patient consciously or subconsciously manipulates their pacemaker/defibrillator pulse generator, often resulting in lead dislodgement and device system malfunction. Once dislodgement has occurred, corrective measures include resecuring the system to the pectoralis fascia with redundant anchoring sutures. Unfortunately, patients with Twiddler's syndrome tend to have a high rate of recurrence. This study presents a case series of patients with Twiddler's syndrome and evaluates the strategy of using a nonabsorbable antimicrobial pouch to prevent recurrent lead dislodgement events. METHODS: Pacemaker and defibrillator operative reports were reviewed at a single institution over a time period of 16 years. Historical, fluoroscopic, and intraoperative findings were used to identify 21 patients with strong evidence for Twiddler's syndrome. Patient charts were retrospectively analyzed, and a cohort of 13 patients who received a nonabsorbable antimicrobial pouch was compared to a cohort of eight patients who received other corrective measures. RESULTS: The rate of "retwiddling" events was 0% in the antimicrobial pouch group versus 50% in the suture-only group (P < 0.05). CONCLUSIONS: Among patients requiring device system revision for Twiddler's syndrome, the use of nonabsorbable antimicrobial pouches was associated with significantly fewer recurrences of lead dislodgement events.

Microbial Epidemiology of Infectious Endocarditis in the Intravenous Drug Abuse Population: A Retrospective Study.

INTRODUCTION: The microbial epidemiology differs between infective endocarditis (IE) patients with and without a history of injection drug use. We set out to determine the prevalence and microbial epidemiology of infective endocarditis in our region, the Southeastern USA, to determine if any changes need to be made in empiric antimicrobial treatment. METHODS: The electronic medical record was reviewed for patients with IE between January 2013 and July 2017, which revealed 299 cases. The cases were then sorted between patients with and without a history of injection drug use. The growth of their initial set of blood cultures and side of cardiac involvement were then recorded. Statistical analyses were run on the data sets. RESULTS: There were statistically significant effects associated with both methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas species infections occurring more often in individuals with active injection drug use, while streptococcus and enterococcus infections were more likely to occur in the population of individuals who do not inject drugs. CONCLUSION: In IE patients who use or are suspected of injection drug use, first-line broad-spectrum antibiotics with excellent MRSA and Pseudomonas coverage are essential.