Infective endocarditis by Enterobacter cloacae: a systematic review and meta-analysis.

Enterobacter species are Gram-negative, non-spore-forming, facultative anaerobes typically motile due to the presence of peritrichous flagella. E. cloacae, the species responsible for the majority of Enterobacter infections in humans, is part of the intestinal microbiota and may cause infection in patients that have previously received antimicrobial therapy or who have been admitted to the Intensive Care Unit. E. cloacae may cause several infections, such as pneumonia, urinary tract, skin and soft tissue and intravascular infections. Infective Endocarditis (IE) is a rare disease with notable morbidity and mortality. Even though IE is rarely caused by E. cloacae, these infections can be problematic due to the relative lack of experience in their management. The purpose of this study was to systematically review all published cases of IE by E. cloacae in the literature. A systematic review of PubMed, Scopus and Cochrane library (through 14th November 2020) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE by E. cloacae was performed. A total of 20 studies, containing data of 20 patients, were included. A prosthetic valve was present in 27.8%. Mitral valve was the commonest infected site, followed by aortic valve. Diagnosis was facilitated by transthoracic and transesophageal echocardiography in 38.5% each, while the diagnosis was set at autopsy in 10%. Fever, sepsis, shock and immunologic phenomena were the most common clinical presentations, followed by heart failure. Aminoglycosides, cephalosporins and carbapenems were the most common antimicrobials used. Clinical cure was noted in 75%, while overall mortality was 30%. Development of shock and treatment with the combination of piperacillin with tazobactam were associated with overall mortality.

Infective endocarditis by Klebsiella species: a systematic review.

This study aimed to systematically analyze all cases of infective endocarditis (IE) by Klebsiella species in the literature. A systematic review of PubMed, Scopus and Cochrane library (through 27th January 2021) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE by Klebsiella species was performed. In this review, a total of 66 studies were included, providing data for 67 patients. A prosthetic valve was present in 16.4%, while the most common causative pathogen was K. pneumoniae followed by K. oxytoca. The aortic valve was the most commonly infected intracardiac site, followed by the mitral valve. The diagnosis was based on transthoracic echocardiography in 46.2%, while the diagnosis was set at autopsy in 9.2% of included patients. Blood cultures were positive in 93.8%. Fever and sepsis were the most frequent clinical presentations, followed by embolic phenomena, paravalvular abscess, and heart failure. Cephalosporins, aminoglycosides, and carbapenems were the most frequently used antimicrobials. Surgical treatment along with antimicrobials was performed in 37.3% of included patients. Clinical cure was noted in 80.3%, while the overall mortality was 19.4%. Infection at the aortic valve was independently associated with mortality by IE. This systematic review gives a comprehensive description of IE by Klebsiella and provides information on epidemiology, clinical manifestations, therapeutic strategies and their outcomes.

Diagnostic challenge: an atypical presentation of infective endocarditis.

It is recognised that infective endocarditis is frequently a challenging diagnosis to make, as it may present with a range of non-specific symptoms. A middle-aged man was admitted with an 8-day history of profuse non-bloody diarrhoea and vomiting. He had no medical history and no identifiable risk factors for infective endocarditis, and so this in combination with the patient's atypical symptoms presented a diagnostic challenge. The patient was eventually diagnosed with a Staphylococcus aureus right-sided infective endocarditis. This case report explores the events which led to this diagnosis and demonstrates a number of unique learning points. It also highlights the importance of maintaining an open mind and being prepared to revise an initial diagnosis in the face of medical uncertainty.

Dalbavancin for infective endocarditis: a single centre experience.

Infective endocarditis (IE) is a life-threatening disease, mostly caused by gram-positive cocci, needing a 4-6 weeks antibiotic course. Dalbavancin is a lipoglycopeptide active on gram-positive microorganisms, with a unique pharmacokinetic profile. We describe our experience with dalbavancin to complete the intravenous antibiotic regimen for difficult-to-treat IE cases due to gram-positive bacteria. We treated 10 severely ill patients, each presenting several comorbidities. Seven patients were microbiologically cured from IE, but two patients experienced IE relapse due to the same microrganism. Short-term mortality after dalbavancin was nil, but late mortality (within 1 year of hospital discharge) was 60%. No death was related to dalbavancin therapy. Treatment was generally well tolerated. Dalbavancin may be an option to complete IE treatment in selected cases, once blood culture clearance and improvement of clinical conditions under standard therapy is reached, allowing shortening of hospitalization.

Infective endocarditis by Acinetobacter species: a systematic review.

A. baumannii - A. calcoaceticus complex infections are increasingly frequent, especially in intensive care units. Such infections are associated with a mortality that can be as high as 62%. On the other hand, infective endocarditis (IE) is an uncommon disease with notable morbidity and mortality. Even though IE is rarely caused by Acinetobacter species, these infections can be particularly problematic due to increasing antimicrobial resistance. The purpose of this study was to systemically review all published cases of IE by Acinetobacter species in the literature. A systematic review of PubMed, Scopus and Cochrane library (through 25 April 2020) for studies providing epidemiological, clinical, microbiological as well as treatment data and outcomes of IE by Acinetobacter species was performed. A total of 35 studies, containing data of 37 patients, were included. A prosthetic valve was present in 40.5%, while the most common causative pathogen was A. baumannii - A. calcoaceticus complex, followed by A. lwoffii. Aortic valve was the commonest infected site, followed by mitral valve. Diagnosis was set with transthoracic echocardiography in 48.6%, while the diagnosis was set at autopsy in 20%. Fever and sepsis were the commonest clinical presentations, followed by heart failure and embolic phenomena. Aminoglycosides, cephalosporins and carbapenems were the commonest antimicrobials used. Clinical cure was noted in 70.3%, while overall mortality was 32.4%. Development of heart failure was independently associated with mortality by IE. This systematic review thoroughly describes IE by Acinetobacter and provides information on epidemiology, clinical presentation, treatment and outcomes.

Bilateral, vertical supranuclear gaze palsy following unilateral midbrain infarct.

A 60-year-old man recently admitted for bipedal oedema, endocarditis and a persistently positive COVID-19 swab with a history of anticoagulation on rivaroxaban for atrial fibrillation, transitional cell carcinoma, cerebral amyloid angiopathy, diabetes and hypertension presented with sudden onset diplopia and vertical gaze palsy. Vestibulo-ocular reflex was preserved. Simultaneously, he developed a scotoma and sudden visual loss, and was found to have a right branch retinal artery occlusion. MRI head demonstrated a unilateral midbrain infarct. This case demonstrates a rare unilateral cause of bilateral supranuclear palsy which spares the posterior commisure. The case also raises a question about the contribution of COVID-19 to the procoagulant status of the patient which already includes atrial fibrillation and endocarditis, and presents a complex treatment dilemma regarding anticoagulation.

Fibrous skeleton reconstruction for invasive aortic and mitral valve endocarditis.

Invasive endocarditis of the aortic and mitral valves with involvement of the intervalvular fibrosa is a particular surgical challenge. We describe a technique for aortic and mitral valve replacement with concomitant reconstruction of the intervalvular fibrosa, utilizing a folded bovine pericardial patch (Commando operation).

Rapid-deployment aortic valve replacement in high-risk patients with severe endocarditis.

BACKGROUND: Surgical management of aortic valve endocarditis in high risk patients is controversial and the ideal treatment has not been found yet. We describe a selected series of eight patients treated with rapid-deployment aortic valve prosthesis as a therapeutic solution for minimizing the risks associated with annulus manipulation in case of severe aortic infective endocarditis. METHODS: Eight consecutive patients (five men and three women) with a mean age of 74.3±7.2 years, mean logistic EuroSCORE II of 16.0%±0.1%, affected by aortic native (1 patient), or prosthetic valve endocarditis (7 patients), were treated with Edwards Intuity Elite implantation. Hemodynamic performance and infective data were collected pre-, intra-, and postoperatively with a mean follow-up of 2.7±0.7 years. RESULTS: One case of in-hospital mortality was noted. None of the patients had any embolic or infective complication postoperatively. The cardiopulmonary bypass and aortic cross-clamp times were 148.4±41.6 and 90.5±25.3 min, respectively. The postoperative echocardiographic controls indicated a mean transvalvular gradient of 16.7±3.0 mmHg and one case of paravalvular leaks (2 +). Two patients underwent epigastric permanent pacemaker implantation. During the follow-up, seven patients were alive, with no evidence of symptoms or recurrences of endocarditis or embolic episodes. No new paravalvular leaks were noted, and the mean gradient on the valves was 12.4±3.4 mmHg. CONCLUSIONS: Rapid deployment aortic valve replacement in selected very high-risk patients affected by infective endocarditis could be a reasonable choice with acceptable results. However, further studies are needed to confirm these results.

Surgical Results for Infective Endocarditis Complicated With Cardiogenic Shock.

BACKGROUND: Infective endocarditis remains associated with substantial mortality and morbidity rates, and the presence of acute heart failure (AHF) compromises clinical results after valve surgery; however, little is known in cardiogenic shock (CGS) patients. This study evaluated the clinical results and risk of mortality in CGS patients after valve surgery.Methods and Results:This study enrolled 585 patients who underwent valve surgery for active endocarditis at 14 institutions between 2009 and 2017. Of these patients, 69 (12%) were in CGS, which was defined as systolic blood pressure <80 mmHg and severe pulmonary congestion, requiring mechanical ventilation and/or mechanical circulatory support, preoperatively. The predictors of CGS were analyzed, and clinical results of patients with non-CGS AHF (n=215) were evaluated and compared.Staphylococcus aureusinfection (odds ratio [OR] 2.19; P=0.044), double valve involvement (OR 3.37; P=0.003), and larger vegetation (OR 1.05; P=0.036) were risk factors for CGS. Hospital mortality occurred in 27 (13%) non-CGS AHF patients and in 15 (22%) CGS patients (P=0.079). Overall survival at 1 and 5 years in CGS patients was 76% and 69%, respectively, and there were no significant differences in overall survival compared with non-CGS AHF patients (P=1.000). CONCLUSIONS: Clinical results after valve surgery in CGS patients remain challenging; however, mid-term results were equivalent to those of non-CGS AHF patients.

Double-Valve Heart Disease and Glomerulonephritis Consequent to Abiotrophia defectiva Endocarditis.

Abiotrophia defectiva, a nutritionally deficient streptococcus, is a rare cause of infective endocarditis. It has been associated with hemophagocytic syndrome. We present the first case of A. defectiva infective endocarditis that led to antineutrophil cytoplasmic antibody-associated glomerulonephritis. The patient was a 55-year-old man whose endocarditis affected the mitral and aortic valves. His course was complicated by atrial fibrillation, stroke, and glomerulonephritis. He was successfully treated with antibiotics and dual valve replacement.

Microbiological features, clinical characteristics and outcomes of infective endocarditis in adults with and without hemodialysis: A 10-year retrospective study in Northern Taiwan.

BACKGROUND/PURPOSES: Infective endocarditis (IE) is an important cause of morbidity and mortality in hemodialysis (HD) patients. Data on the differences in the microbiological features as well as clinical characteristics and outcomes of HD and non-HD patients with IE are limited. METHODS: Medical records of patients (aged over 20 years) with IE were retrospectively reviewed from January 2008 to June 2017 in a tertiary care center in Northern Taiwan. Those with definite or possible IE were included in the study. The clinical characteristics, microbiological results, echocardiographic findings and outcomes of patients were analyzed. RESULTS: Of the 183 patients with definite or possible IE, 47 had undergone HD and 136 had not. Advanced age (67.3 vs. 61.5 years, p = 0.027), more female gender (51.1% vs. 33.8%, p = 0.036), comorbidities (a high Charlson comorbidity index, 8.17 vs. 4.21, p < 0.001), diabetes mellitus (68.1% vs. 35.3%, p < 0.001), and hypertension (85.1% vs. 53.7%, p < 0.001) were commonly observed in HD patients than in non-HD patients. The yield rate of the blood cultures was higher in HD group than in non-HD group (89.4% vs. 72.8%, p = 0.02). The proportion of methicillin-resistant Staphylococcus aureus was significantly higher in HD group than in non-HD group (31.9% vs. 5.9%, p < 0.001). HD patients versus non-HD patients had higher cardiac complication rates (38.3% vs. 14%, p < 0.001). CONCLUSION: Advanced age, sex (female), comorbidities, diabetes mellitus, and hypertension were more common in HD patients than in non-HD patients with IE. HD patients had higher proportion of methicillin-resistant S. aureus and cardiac complication rates than non-HD patients with IE. Culture-negative IE was more common in non-HD patients.

The Utility of Echocardiography in Pediatric Patients with Structurally Normal Hearts and Suspected Endocarditis.

The objective of this study was to evaluate the utility of transthoracic echocardiography (TTE) in children with structurally normal hearts suspected of having infective endocarditis (IE). We hypothesized that the diagnostic yield of TTE is minimal in low-risk patients with normal hearts. We performed a retrospective chart review of TTEs performed for concern for endocarditis at a pediatric tertiary care referral center in Portland, Oregon. Three hundred patients met inclusion criteria (< 21 years old, completed TTE for IE from 2005 to 2015, no history of congenital heart disease or endocarditis). We recorded findings that met the modified Duke criteria (MDC) including fever, positive blood culture, and vascular/immunologic findings; presence of a central line; whether or not patients were diagnosed with IE clinically; and if any changes to antibiotic regimens were made based on TTE. Ten patients (3%) had echocardiograms consistent with IE. When compared to the clinical diagnosis of IE, the positive predictive value (PPV) of one positive blood culture without other major/minor MDC was 0. Similarly, the PPV of two positive blood cultures without other major/minor criteria was 0.071. Patients should be evaluated using the MDC to assess the clinical probability of IE prior to performing a TTE. Patients with a low probability for IE should not undergo TTE as it has a low diagnostic yield and patients are unlikely to be diagnosed with disease.

The Mitral Monobloc: A Simplification for Intervalvular Fibrous Body Reconstruction in Endocarditis.

The only viable option in prosthetic valve endocarditis with extensive abscess of the aorto-mitral curtain is radical debridement and reconstruction of the intravalvular fibrous body. This report details a simplified intravalvular fibrous body reconstruction technique.

Comparison of intraoperative versus intraoperative plus postoperative hemoadsorption therapy in cardiac surgery patients with endocarditis.

Infective endocarditis is caused by a bacterial infection of the endocardial surface, and despite improvements in surgical interventions and antimicrobial therapy, mortality remains high. Recently published data suggest that intraoperative hemoadsorption therapy might represent a promising treatment option; however, randomized data still lack, and a comparative study on the intraoperative versus intraoperative plus postoperative use of CytoSorb has not yet been performed. We hypothesized that patients developing intraoperative renal failure benefit from additional postoperative CytoSorb treatment in terms of outcome. We examined the application of hemoadsorption therapy in 20 endocarditis patients separated into two groups: (1) sole intraoperative versus (2) intraoperative plus postoperative treatment, with regard to inflammatory and hemodynamic status, the postoperative course including development of complications, extent of extracorporeal organ support, and outcome. Despite an obviously more pronounced disease severity in the intraoperative plus postoperatively treated patients as evidenced by a higher initial European System for Cardiac Operative Risk Evaluation score, higher reoperation rate, longer cardiopulmonary bypass times, a worse inflammatory status, and perioperative development of acute renal failure, we observed a clear and comparable stabilization in hemodynamics and inflammatory parameters in both groups. More importantly and despite a higher rate of postoperative complications and a longer intensive care unit stay, patients from the intraoperative plus postoperative group showed an equal intensive care unit and 90-day survival compared to patients treated only intraoperatively. Our data suggest that postoperative continuation of hemoadsorption treatment might be beneficial in patients with endocarditis who develop perioperative renal failure in combination with severe hemodynamic instability and high-grade intraoperative findings.

Rare Simultaneous Left and Right-Sided Native Valve Infective Endocarditis Caused by Rare Bacterium.

Simultaneous left and right-sided native valve infective endocarditis (IE) is rare. Staphylococcus aureus was the predominant organism for bilateral IE. Shunt diseases are common risk factors of both-sided IE. Streptococcus anginosus (S. anginosus) is usually associated with pyogenic infections, but rarely a cause of IE. Here we present an extremely rare case of simultaneous left and right-sided native valve IE affecting the mitral and tricuspid valves caused by S. anginosus in an adult patient that has not been reported in the literature previously, particularly without the most frequent predisposing factors of IE. A 66-year-old man was admitted due to generalized fatigue, chills, malaise, and intermittent fevers for 1 year. A grade III-IV/VI systolic murmur at the mitral area and a III/VI systolic murmur at the tricuspid area were noted on physical examination. Laboratory evaluation revealed an elevated erythrocyte sedimentation rate and C-reactive protein level, and high fasting blood glucose. Blood culture was positive for S. anginosus. Echocardiography revealed vegetations in both sides of the heart: a large mitral valve vegetation with severe mitral regurgitation, as well as another vegetation on the tricuspid valve with moderate regurgitation. The case highlights a rare pathogen of both-sided IE, a rare presentation of S. anginosus infection, and several points worthy of note in echocardiography of IE.

Chain pain following cardiac surgery in a 35-year-old man.

CLINICAL INTRODUCTION: A 35-year-old man with multiple cardiovascular risk factors presented with a recent history of fever and acute heart failure. His initial echocardiogram showed evidence of severe aortic regurgitation due to ongoing infective endocarditis. Preoperative coronary angiography revealed no coronary abnormalities. Urgent aortic valve replacement was performed and a 29 mm St Jude mechanical valve was implanted. While blood and resected valvular tissue cultures were negative for bacteria, a PCR-based analysis revealed the presence of penicillin-sensitive Streptococcus pneumoniae. Echocardiographic follow-up study at day 3 showed excellent mechanical valve function with no persistent signs of endocarditis. Eight days after surgery, our patient presented with severe chest pain. The ECG is shown in figure 1A and coronary angiography was performed for diagnostic confirmation (figure 1B-D and online supplementary video 1).DC1SP110.1136/heartjnl-2018-313577.supp1Supplementary file 1 heartjnl;105/3/234/F1F1F1Figure 1(A) 12-lead ECG. (B, C) Selective angiogram of the left main, left anterior descending artery and circumflex artery. (D) Aortic root angiography. QUESTION: Which of the following is most likely the diagnostic?Occlusion of the left anterior descending coronary arteryDissection of the left anterior descending coronary arteryValsalva aneurysm presenting as an acute coronary syndromeLeft anterior descending coronary artery spasmLeft main coronary aneurysm.