Long-term Oral Suppressive Antimicrobial Therapy in Infective Endocarditis (SATIE Study): An Observational Study.

Background: The role of suppressive antimicrobial therapy (SAT) in infective endocarditis (IE) management has yet to be defined. The objective of this study was to describe the use of SAT in an IE referral center and the patients' outcomes. Methods: We conducted a retrospective observational study in a French IE referral center (Paris). All patients with IE who received SAT between 2016 and 2022 were included. Results: Forty-two patients were included (36 male [86%]; median age [interquartile range {IQR}], 73 [61-82] years). The median Charlson Comorbidity Index score (IQR) was 3 (1-4). Forty patients (95%) had an intracardiac device. The most frequent microorganisms were Enterococcus faecalis (15/42, 36%) and Staphylococcus aureus (12/42, 29%). SAT indications were absence of surgery despite clinical indication (28/42, 67%), incomplete removal of prosthetic material (6/42, 14%), uncontrolled infection source (4/42, 10%), persistent abnormal uptake on nuclear imaging (1/42, 2%), or a combination of the previous indications (3/42, 7%). Antimicrobials were mainly doxycycline (19/42, 45%) and amoxicillin (19/42, 45%). The median follow-up time (IQR) was 398 (194-663) days. Five patients (12%) experienced drug adverse events. Five patients (12%) presented with a second IE episode during follow-up, including 2 reinfections (different bacterial species) and 3 possible relapses (same bacterial species). Fourteen patients (33%) in our cohort died during follow-up. Overall, the 1-year survival rate was 84.3% (73.5%-96.7%), and the 1-year survival rate without recurrence was 74.1% (61.4%-89.4%). Conclusions: SAT was mainly prescribed to patients with cardiac devices because of the absence of surgery despite clinical indication. Five (12%) breakthrough second IE episodes were reported. Prospective comparative studies are required to guide this empirical practice.

Competencias cognitivas sobre profilaxis antibiótica de endocarditis infecciosa en estudiantes de odontología

Introducción: La endocarditis infecciosa es una enfermedad con riesgo de mortalidad que se puede originar por un tratamiento odontológico. Por ello, los cirujanos dentistas deben tener conocimientos básicos sobre la prevención de endocarditis infecciosa. Objetivo: Determinar el nivel de conocimientos sobre la profilaxis antibiótica de endocarditis infecciosa previa a procedimientos odontológicos en estudiantes de pregrado y posgrado de estomatología. Métodos: Se diseñó un estudio descriptivo y transversal cuya muestra estuvo formada por 74 estudiantes de pregrado y 234 de posgrado de la carrera de Estomatología de la Universidad Científica del Sur en el año 2019. Se empleó un cuestionario previo validado en el Perú, conformado por 20 preguntas de opción múltiple y dividido en 4 dimensiones (epidemiología, etiopatogenia, indicación y farmacología de la profilaxis antibiótica de endocarditis infecciosa). Los resultados se categorizaron en nivel de conocimiento bajo, regular y alto. Resultados: El 73,1 % de los estudiantes presentó un nivel de conocimiento global bajo, mientras que el 23,7 % presentó un nivel regular y el 3,2 %; un nivel alto. La calificación promedio fue 8,71 ± 2,78 [IC95 % 8,40 a 9,10]. Los estudiantes de pregrado tuvieron un puntaje de 8,64 ± 2,72 [IC95 % 8,01 a 9,26] y los de posgrado; 8,74 ± 2,80 [IC95 % 8,38 a 9,10]. Conclusión: El nivel de conocimiento sobre profilaxis antibiótica para la prevención de endocarditis infecciosa previa a procedimientos odontológicos es bajo en pregrado y posgrado.

Introduction: Infective endocarditis is a potentially life-threatening disease that can be caused by dental treatment. Therefore, dental surgeons should have basic knowledge about the prevention of infective endocarditis. Objective: To determine the level of knowledge of antibiotic prophylaxis of infective endocarditis prior to dental procedures in undergraduate and postgraduate students of stomatology at the Universidad Cientifica del Sur, Lima - Peru. Method: A descriptive and cross-sectional study was designed with a sample of 74 undergraduate and 234 graduate students of the Universidad Cientifica del Sur Stomatology career in 2019. A questionnaire previously validated in Peru was used, consisting of 20 multiple-choice questions, and divided into 4 dimensions (epidemiology, etiopathogenesis, indication, and pharmacology of antibiotic prophylaxis of infective endocarditis). The results were categorized into low, regular, and high levels of knowledge. Results: 73.1% of the students presented a low level of global knowledge, while 23.7% presented a regular level, and 3.2% a high level. The average score was 8.71 ± 2.78 [95% CI 8.40 to 9.10]. Undergraduate students had a score of 8.64 ± 2.72 [95% CI 8.01 to 9.26] and graduate students; 8.74 ± 2.80 [95% CI 8.38 to 9.10]. Conclusion: The level of knowledge of antibiotic prophylaxis for the prevention of infective endocarditis prior to dental procedures was predominantly low in undergraduate and postgraduate students.

Avaliação da condição de saúde bucal em pacientes que apresentam risco de endocardite / Evaluation of oral health condition in patients at risk for endocarditis

Objetivo: Avaliar a condição de saúde bucal em pacientes com alto risco de desenvolver endocardite infecciosa atendidos em um hospital de referência do Brasil. Métodos: Utilizou-se de dados secundários obtidos de prontuários de pacientes internados na enfermaria de cardiologia do Hospital Dom Pedro II. Os dados foram coletados utilizando uma ficha padronizada a partir da evolução odontológica dos pacientes, na qual estão registradas, as informações obtidas na consulta, contidas no prontuário médico, bem como as informações de saúde bucal. Após a coleta, os dados categorizados em alto e baixo risco de endocardite e analisados através do teste qui-quadrado de Pearson ou teste exato de Fisher, considerando um intervalo de confiança de 95%. Resultados: Um total de 583 prontuários de adultos admitidos na enfermaria de cardiologia no período de janeiro de 2017 a agosto de 2020 foram analisados. Destes foram incluídos na amostra do estudo 216 prontuários. A prevalência de endocardite infecciosa foi de 11,5% (n =18) e o risco de endocardite infecciosa foi considerado alto para a maioria (n = 196; 93,3%). Queixa oral foi reportada por 15,1% (n = 30) e a higiene oral foi considerada como deficiente para a maior parte dos pacientes (n = 95; 48,7%). A necessidade de tratamento odontológico foi verificada em 66,5% da amostra (n = 119). Conclusão: A condição de saúde bucal dos pacientes com condições cardíacas predisponentes a infecção por endocardite não é satisfatória. Uma boa parte apresenta necessidades de tratamento invasivo, o que aumenta o risco de bacteremias.

Aim: To assess the oral health status of patients at high risk of developing infective endocarditis treated at a referral hospital in Brazil. Methods: Secondary data obtained from medical records of patients admitted to the cardiology ward of Hospital Dom Pedro II were used. Data were collected using a standardized form based on the patients' dental evolution, in which the information obtained in the consultation was contained in the medical record, as well as the oral health information was recorded. After collection, the data were categorized into high and low risk of endocarditis and analyzed using Pearson's chi-square test or Fisher's exact test, considering a confidence interval of 95%. Results: A total of 583 medical records of adults admitted to the cardiology ward from January 2017 to August 2020 were analyzed. Of these, 216 medical records were included in the study sample. The prevalence of infective endocarditis was 11.5% (n =18), and the risk of infective endocarditis was considered high for the majority (n = 196; 93.3%). Oral complaints were reported by 15.1% (n = 30), and oral hygiene was considered deficient for most patients (n = 95; 48.7%). The need for dental treatment was verified in 66.5% of the sample (n = 119). Conclusion: The oral health status of patients with cardiac conditions predisposing to endocarditis infection is not satisfactory. A considerable portion needs invasive treatment, which increases the risk of bacteremia.

Serratia marcescens Endocarditis: A Case Report and Literature Review.

Serratia marcescens is a rarely implicated agent in endocarditis. We describe a case of a patient that underwent aortic and mitral valve replacement for Streptococcus agalactiae endocarditis. Four months later, he was readmitted with an ischemic stroke and fever. Physical examination and repetitive transthoracic echocardiogram were unremarkable. The initial blood cultures were negative. Due to sustained fever, vancomycin, gentamicin and piperacillin-tazobactam were initiated. On subsequent blood cultures, Serratia marcescens was isolated and antibiotics switched to ertapenem and gentamicin. In addition to cerebral emboli, a splenic embolus was found. The PET/CT revealed an abnormal hypercaptation in the mitral bioprosthesis. The patient was treated for six weeks. There are no current specific recommendations regarding the treatment of Serratia marcescens endocarditis. It is widely accepted that treatment should be prolonged and include a combination of antimicrobial agents. Morbidity and mortality are high, particularly when there's the need for surgical replacement. In this case, however, the patient ended-up only requiring medical treatment due to the favourable response.

A Serratia marcescens é um agente raro de endocardite. Descrevemos o caso de um doente submetido a substituição das válvulas aórtica e mitral por endocardite causada por Streptococcus agalactiae. Quatro meses após, é readmitido por evento cerebral isquémico e febre. Ao exame objetivo não evidenciava alterações e os ecocardiogramas transtorácicos eram normais. As hemoculturas colhidas à admissão foram estéreis. O doente manteve-se febril, iniciando-se empiricamente vancomicina, gentamicina e piperacilina-tazobactam. Após isolamento de Serratia marcescens em hemoculturas subsequentes, a antibioterapia foi ajustada para ertapenem e gentamicina. Para além de um êmbolo cerebral, foi encontrada embolia esplénica e hipercaptação anormal na prótese mitral biológica em PET. Foi efetuado tratamento durante seis semanas. Não existem recomendações específicas sobre o tratamento de endocardite por Serratia marcescens, mas deve ser prolongado e com terapêutica combinada. A morbimortalidade é elevada, sobretudo quando há necessidade de cirurgia. Neste caso, a evolução clínica favorável do doente permitiu o tratamento médico exclusivo.

Caries Experience and Knowledge About Oral Health Importance Among Children with Congenital Heart Diseases in Kosovo

Abstract Objective: To determine the dental health of children with Congenital Heart Diseases (CHD) and to evaluate the parents' knowledge of the importance of oral health and the risk of Bacterial Endocarditis. Material and Methods: This research included 140 children divided into the study group (80 children with CHD) and the control group (60 healthy children). The children were from different parts of Kosova, aged between 3-15. The parents were asked to complete a questionnaire containing demographic data (age and gender), general and special medical history (CHD types), knowledge about oral health importance and risk of bacterial endocarditis, and data about the daily oral hygiene child. The caries experience was reported using the DMFT/dmft index. Results: The average value of the dmft index was 6.7 for the study group and 5.62 for the control group, while the average value of DMFT index for the study group was 4.1, and for the control group was 3.47 (p>0.05). About 68.7% of parents of children with CHD were informed about their risk during dental interventions. However, knowledge was insufficient about the importance of oral health and dental prophylactic measures once only 32.7% of them were aware of those measures. Conclusion: No difference was observed between healthy and CHD children in caries experience and frequency of daily tooth brushing. Our findings provide evidence of a lack of knowledge about the importance of oral health and dental prophylactic measures among parents with CHD children (AU).

Should We Quantify Valvular Calcifications on Cardiac CT in Patients with Infective Endocarditis?

BACKGROUND: Evaluate the impact of valvular calcifications measured on cardiac computed tomography (CCT) in patients with infective endocarditis (IE). METHODS: Seventy patients with native IE (36 aortic IE, 31 mitral IE, 3 bivalvular IE) were included and explored with CCT between January 2016 and April 2018. Mitral and aortic valvular calcium score (VCS) were measured on unenhanced calcium scoring images, and correlated with clinical, surgical data, and 1-year death rate. RESULTS: VCS of patients with mitral IE and no peripheral embolism was higher than those with peripheral embolism (868 (25-1725) vs. 6 (0-95), p < 0.05). Patients with high calcified mitral IE (mitral VCS > 100; n = 15) had a lower rate of surgery (40.0% vs.78.9%; p = 0.03) and a higher 1-year-death risk (53.3% vs. 10.5%, p = 0.04; OR = 8.5 (2.75-16.40) than patients with low mitral VCS (n = 19). Patients with aortic IE and high aortic calcifications (aortic VCS > 100; n = 18) present more frequently atypical bacteria on blood cultures (33.3% vs. 4.8%; p = 0.03) than patients with low aortic VCS (n = 21). CONCLUSION: The amount of valvular calcifications on CT was associated with embolism risk, rate of surgery and 1-year risk of death in patients with mitral IE, and germ's type in aortic IE raising the question of their systematic quantification in native IE.

Aortic Root Replacement for Destructive Endocarditis - Clinic and Microbiology.

INTRODUCTION: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. METHODS: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. RESULTS: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. CONCLUSION: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Caracterización de pacientes con endocarditis infecciosa / Characterization of patients with infective endocarditis

RESUMEN Introducción: la endocarditis infecciosa es una enfermedad mortal. A pesar de las mejoras en su manejo, se asocia a una elevada mortalidad y complicaciones graves. Objetivo: caracterizar los pacientes diagnosticados con EI en el Hospital Clínico Quirúrgico Docente Celia Sánchez Manduley, en el período de enero de 2015 a diciembre de 2020. Métodos: se realizó un estudio descriptivo, transversal y retrospectivo en el Hospital Clínico Quirúrgico Docente Celia Sánchez Manduley, en el período de enero de 2015 a diciembre de 2020. La población en estudio la constituyeron los 34 pacientes diagnosticados según los criterios de Duke modificados. Las variables utilizadas fueron: edad, sexo, válvula afectada, localización, estado al egreso, manifestaciones clínicas y exámenes complementarios practicados. Mediante la estadística descriptiva se realizó el cálculo de frecuencia absoluta, media aritmética con desviación estándar y cálculo porcentual. Las variables cuantitativas fueron comparadas según la t de Student. Resultados: el grupo etario más afectado fue el de 61 - 70, sin diferencias entre sexos. Los casos asociados a dispositivos intracardiacos prevalecieron. Se determinaron valores de hemoglobina (105,2g/dL DE±13,0), leucograma (16,8mmol/L DE±0,2), Proteína C reactiva (96,2mg/L DE±3,2), eritrosedimentación (101,0 mm/h DE±20,1), y creatinina (149,0 mmol/L DE±24,3). En el 59 % de los casos no se pudo determinar agente causal. Conclusiones: la endocarditis infecciosa es más frecuente en adultos mayores sin distinción de sexos. Predominan los casos con dispositivos intracardiacos, los cuales en su mayoría presentan valores elevados de leucograma eritrosedimentación, creatinina y de Proteína C reactiva. En la mayoría, los hemocultivos resultaron negativos.

ABSTRACT Introduction: infective endocarditis is a fatal disease. Despite improvements in its management, it is still associated with high mortality rate and severe complications. Objective: to characterize patients diagnosed with infective endocarditis. Methods: a descriptive, cross-sectional and retrospective study was conducted at Celia Sanchez Manduley Clinical-surgical Teaching Hospital, in the period from January 2015 to December 2020. The study population comprised 34 patients diagnosed according to the modified Duke criteria. The variables analyzed were: age, sex, affected valve, and location, status at discharge, clinical manifestations and complementary examinations performed. Descriptive statistics was applied to calculate absolute frequency, arithmetic mean with standard deviation and percentage calculation. Quantitative variables were compared according to Student's t test. Results: the most affected age group was 61 - 70, with no differences between sexes. Cases associated with intracardiac devices prevailed. Hemoglobin (105,2g/dL DE±13,0), leukogram (16,8mmol/L DE±0,2), C-reactive protein (96,2mg/L DE±3.2), erythrocyte sedimentation rate (101,0 mm/h DE±20,1), and creatinine (149,0 mmol/L DE±24,3) were determined. In 59 % of the cases no causative agent could be determined. Conclusions: infective endocarditis is more frequent in older adults without distinction of sex. Cases with Intracardiac devices predominate, most of them presenting elevated values of leukogram, erythrocyte sedimentation, creatinine and C-reactive protein. Blood cultures were negative in most cases.

Comparison of mortality, stroke, and relapse for methicillin-resistant versus methicillin-susceptible Staphylococcus aureus infective endocarditis: a retrospective cohort study.

The purpose of this study was to compare survival, relapse, and stroke for patients with methicillin-resistant Staphylococcus aureus (MRSA) vs methicillin-susceptible S. aureus (MSSA) infective endocarditis (IE). In this retrospective study, the primary outcome of death and secondary outcomes of stroke and relapse were compared using multivariable Cox proportional hazards regression. Surgical treatment was adjusted for as a time-dependent variable. In total, 355 patients with at least one episode of IE caused by S. aureus were included. Patients with MRSA IE had higher mortality than those with MSSA IE (HR 1.34, 95% CI 1.01-1.77), but did not have a higher risk of stroke (HR 0.75, 95% CI 0.43-1.32) or relapse (HR 0.89, 95% CI 0.26-3.05). The cumulative incidence of relapse was very small. Among patients with IE caused by S. aureus MRSA infection is associated with higher mortality than MSSA infection.

Kissing Lesion of Mitral Valve - A Case Report.

Aortic valve endocarditis can lead to secondary involvement of aorto-mitral curtain and the adjacent anterior mitral leaflet (AML). The secondary damage to AML is often caused by the infected jet of aortic regurgitation hitting the ventricular surface of the mitral leaflet, or by the pronounced bacterial vegetation that prolapses from the aortic valve into the left ventricular outflow tract. This is called 'kissing lesion'. We describe a patient with infective endocarditis of the aortic valve causing perforation of both noncoronary cusp of aortic valve and the AML, which is rare.

Kissing lesion of mitral valve - a case report

Abstract Aortic valve endocarditis can lead to secondary involvement of aorto-mitral curtain and the adjacent anterior mitral leaflet (AML). The secondary damage to AML is often caused by the infected jet of aortic regurgitation hitting the ventricular surface of the mitral leaflet, or by the pronounced bacterial vegetation that prolapses from the aortic valve into the left ventricular outflow tract. This is called 'kissing lesion'. We describe a patient with infective endocarditis of the aortic valve causing perforation of both noncoronary cusp of aortic valve and the AML, which is rare.

Post-mortem findings in Staphylococcus aureus acute infective endocarditis.

Infective endocarditis (IE) is a microbial infection of the heart valves or the mural endocardium that leads to the formation of vegetations composed of thrombotic debris and microorganisms often associated with the destruction of the cardiac tissues. Most of the infections are bacterial (bacterial endocarditis), although fungi and other microorganisms can be etiological agents. Causative organisms differ among the major high-risk groups. Virulent microorganisms like Staphylococcus aureus, commonly found on the skin, can infect normal or deformed valves and are responsible for 20-30% of all IE cases. Staphylococcus aureus is the major offender in IE among intravenous drug abusers. Acute infective endocarditis is typically caused by infection of a previously normal heart valve by a highly virulent organism (e.g., Staphylococcus aureus) that rapidly produces necrotizing and destructive lesions. These infections may be difficult to cure with antibiotics, and despite appropriate treatment, death can ensue within days to weeks. Here we present autopsy findings of a 31-year-old male patient who died of acute infective endocarditis caused by Staphylococcus aureus as the causative organism.

Modified Danielson Technique for Prosthetic Aortic Valve Endocarditis and Aortoventricular Discontinuity.

Endocarditis is a devastating complication of prosthetic aortic valve replacement. The infective process can destroy aortic annulus tissue, making conventional surgical valve replacement difficult or impossible and causing aortoventricular discontinuity. Several treatment techniques have been proposed. One of these, the Danielson technique, involves translocating the aortic valve to the native ascending aorta, débriding the abscess cavity, closing the coronary ostia, and bypassing the coronary arteries with a Y anastomosis between 2 vein grafts. We describe our use of a modified Danielson technique in a 68-year-old man with advanced prosthetic valve endocarditis that was associated with aortic annulus destruction and aortoventricular discontinuity. This modified technique enables safer, more secure anchoring of a replacement valve, reduces the risks and concerns associated with bypass grafts, and successfully treats aortoventricular discontinuity.

Surgical Options for Aortic Root Replacement in Destructive Endocarditis.

OBJECTIVE: To analyze patients' preoperative characteristics, surgical data, postoperative courses, and short- and long-term outcomes after implantation of different full-root prostheses for destructive aortic valve endocarditis. METHODS: Between 1999 and 2018, 80 patients underwent aortic root replacement due to infective endocarditis in our institution. We analyzed the abovementioned data with standard statistical methods. RESULTS: The Freestyle stentless porcine prostheses were implanted in 53 (66.25%) patients, biological valve conduits in 13 (16.25%), aortic root homografts in nine (11.25%), and mechanical valve conduits in five (6.25%). There were no significant preoperative differences between the groups. The incidence of postoperative complications and intensive care unit length of stay did not differ significantly between the groups. The 30-day mortality rate was low among Freestyle patients (n=8, 15.1%) and high in the mechanical conduit cohort (n=3, 60%), though with borderline statistical significance (P=0.055). The best mean survival rates were observed after homograft (13.7 years) and stentless prosthesis (8.1 years) implantation, followed by biological (2.8 years) and mechanical (1.4 years) conduits (P=0.014). The incidence of reoperations was low in the mechanical conduit group (0) and stentless bioroot group (n=1, 1.9%), but two (15.4%) patients with biological conduits and three (33.3%) patients with homografts required reoperations in the investigated follow-up period (P=0.005). CONCLUSION: In patients with the destructive form of aortic valve endocarditis, homografts and stentless porcine xenografts offer better survival rates than stented valve conduits; however, the reoperation rate among patients who received homograft valves is high.

Surgical options for aortic root replacement in destructive endocarditis

Abstract Objective: To analyze patients' preoperative characteristics, surgical data, postoperative courses, and short- and long-term outcomes after implantation of different full-root prostheses for destructive aortic valve endocarditis. Methods: Between 1999 and 2018, 80 patients underwent aortic root replacement due to infective endocarditis in our institution. We analyzed the abovementioned data with standard statistical methods. Results: The Freestyle stentless porcine prostheses were implanted in 53 (66.25%) patients, biological valve conduits in 13 (16.25%), aortic root homografts in nine (11.25%), and mechanical valve conduits in five (6.25%). There were no significant preoperative differences between the groups. The incidence of postoperative complications and intensive care unit length of stay did not differ significantly between the groups. The 30-day mortality rate was low among Freestyle patients (n=8, 15.1%) and high in the mechanical conduit cohort (n=3, 60%), though with borderline statistical significance (P=0.055). The best mean survival rates were observed after homograft (13.7 years) and stentless prosthesis (8.1 years) implantation, followed by biological (2.8 years) and mechanical (1.4 years) conduits (P=0.014). The incidence of reoperations was low in the mechanical conduit group (0) and stentless bioroot group (n=1, 1.9%), but two (15.4%) patients with biological conduits and three (33.3%) patients with homografts required reoperations in the investigated follow-up period (P=0.005). Conclusion: In patients with the destructive form of aortic valve endocarditis, homografts and stentless porcine xenografts offer better survival rates than stented valve conduits; however, the reoperation rate among patients who received homograft valves is high.