Endocarditis infecciosa de válvula nativa: factores asociados a resultados adversos / Mortality predictors in patients with native valve infec tive endocarditis

Resumen Introducción : La mortalidad de la endocarditis infec ciosa (EI) en Argentina continúa siendo elevada. El obje tivo del trabajo fue describir las características clínicas e identificar factores asociados a mortalidad en pacientes con EI de válvula nativa. Métodos : Estudio de cohorte retrospectiva que inclu yó pacientes adultos con diagnóstico de EI de válvula nativa internados durante 2011-2021. Resultados : Se incluyeron 129 pacientes con una edad promedio de 66±17 años. El organismo responsa ble más frecuente (38.8%, n = 50) fue el Staphylococcus aureus (SA). El 63.6% presentó criterios de indicación quirúrgica. La mortalidad durante la internación fue del 22.5%. En el análisis multivariado que incluyó índice de comorbilidad Charlson, infección por SA y la presencia de criterios de indicación quirúrgica, se observó un OR ajustado de mortalidad de 1.32 (IC95% 1.10-1.57; p = 0.003), 2.75 (IC95% 1.11-6.8; p = 0.028) y 4.14 (IC95% 1.34-12; p = 0.013), respectivamente. En el análisis mul tivariado para mortalidad alejada que agregó el criterio quirúrgico y la realización de cirugía durante la inter nación, se observó un OR ajustado de 1.62 (IC95% 1.31- 2.00; p < 001), 0.77 (IC95% 0.31-1.93; p = 0.58), 7.49 (IC95% 2.07-27.07; p = 0.002) y 0.21 (IC95% 0.06-0.70; p = 0.01), respectivamente. Conclusiones : La mortalidad de la EI se asoció al grado de comorbilidad previa, a la forma de presenta ción y, en relación inversa, a la realización oportuna del tratamiento quirúrgico.

Abstract Introduction : Mortality of infective endocarditis (IE) in Argentina continues to be high. The aim objective was to describe the clinical characteristics and identify factors associated with in-hospital and long-term mortality in patients with native valve IE. Methods : Retrospective cohort study including adult patients with diagnosis of native valve IE, hospitalized during 2011-2021. Results : A total of 129 patients with a mean age of 66±17 years were included. The most frequent respon sible organism was Staphylococcus aureus (SA) (38.8%). Surgical indication criteria were present in 63.6% of the patients. Mortality during hospitalization was 22.5% .In the multivariate analysis that included Charlson comorbidity index, SA infection and the presence of surgical indication criteria, an adjusted OR of mor tality of 1.32 (95%CI 1.10-1.57; p = 0.003), 2.75 (95%CI 1.11-6.8; p = 0.028) and 4.14 (95%CI 1.34-12; p = 0.013), respectively, was observed. In the multivariate analysis for long term mortality, that added surgical indication criteria and the performance of surgery during hospitalization, an adjusted OR of 1.62 (CI95% 1.31-2.00; p<001), 0.77 (95%CI 0.31-1.93; p = 0.58), 7.49 (95%CI 2.07-27.07; p = 0.002) and 0.21 (95%CI 0.06-0.70; p = 0.01), respec tively, was observed. Conclusions : Mortality in IE was associated with the degree of previous comorbidity, with the presence of surgical indication criteria and, inversely, with the timely completion of surgical treatment.

Embolia pulmonar en endocarditis infecciosa asociada a marcapasos: reporte de un caso y revisión de la literatura / Pulmonary embolism in infective endocarditis associated with pacemaker: report of a case and review of the literature

Introducción: Una de las complicaciones más temidas de la endocarditis infecciosa (EI) asociada a marcapasos es la embolia pulmonar. Presentamos el caso de una paciente con diagnóstico actual de EI asociada a marcapasos, que luego de la extracción del dispositivo por vía percutánea presentó síntomas de embolia pulmonar confirmada mediante estudios por imágenes. Objetivos: Conocer el manejo y la evolución intrahospitalarios y a los 18 meses de la embolia pulmonar en el contexto de una endocarditis infecciosa asociada a marcapasos. Materiales y métodos: Búsqueda bibliográfica efectuada en PubMed. Relato del caso clínico: evaluación clínica, presentación de los estudios complementarios y tratamiento. Seguimiento del caso. Resultados: Paciente de 68 años, sexo femenino, con antecedente de implantación de marcapaso definitivo bicameral hace 2 años. Síndrome febril prolongado sin foco aparente, con hemocultivos que fueron positivos para Staphylococcus aureus meticilino-resistente. En el ecocardiograma transesofágico presentaba múltiples vegetaciones en aurícula derecha asociadas con los catéteres. Con base en la anamnesis, el examen físico y los hallazgos en exámenes específicos, se pudo lograr el diagnóstico de EI asociada a marcapasos. Se indicó tratamiento antibiótico y la remoción completa percutánea del dispositivo. Luego del procedimiento presentó disnea súbita confirmándose mediante estudio de centellograma ventilación-perfusión el diagnóstico de embolia pulmonar. Completó el tratamiento antibiótico (vancomicina durante 6 semanas) y fue dada de alta. Durante el seguimiento no presentó nuevas infecciones u otras complicaciones. Conclusión: En nuestro caso, la embolia pulmonar no generó modificaciones en la morbimortalidad intrahospitalaria ni en el seguimiento a 18 meses.

Introduction: One of the most feared infective endocarditis (IE) complications associated with pacemaker is pulmonary embolism. We present the case of a patient with a current diagnosis of pacemaker-associated IE who presented symptoms of pulmonary embolism confirmed by imaging studies after percutaneous removal of the device. Objectives: to know the management and evolution, in-hospital and at 18 months of pulmonary embolism in the context of infective endocarditis associated with pacemaker. Materials and methods: Bibliographic search carried out in PubMed. Clinical case report: clinical evaluation, presentation of complementary studies, and treatment. Follow up on the case. Results: 68-year-old patient with a history of dual chamber permanent pacemaker implantation 2 years ago. Prolonged febrile syndrome with no apparent focus, with positive blood cultures for methicillin-resistant Staphylococcus aureus. The transesophageal echocardiogram showed multiple vegetations associated in right atrial with the catheters. Based on the history, physical examination, and findings in specific tests, the diagnosis of IE associated with DEIP could be achieved. Antibiotic treatment and complete percutaneous removal of the device were indicated. After the procedure, he presented sudden dyspnea, confirming the diagnosis of pulmonary embolism in a ventilation-perfusion scintigram study. She completed the antibiotic treatment (vancomycin for 6 weeks) and was discharged. During follow-up, there were no new infections or other complications. Conclusion: in our patient pulmonary embolism did not generate changes in in-hospital morbidity and mortality or in the 18-month follow-up.

Embolia pulmonar en endocarditis infecciosa asociada a marcapasos: reporte de un caso y revisión de la literatura

Introducción: Una de las complicaciones más temidas de la endocarditis infecciosa (EI) asociada a marcapasos es la embolia pulmonar. Presentamos el caso de una paciente con diagnóstico actual de EI asociada a marcapasos, que luego de la extracción del dispositivo por vía percutánea presentó síntomas de embolia pulmonar confirmada mediante estudios por imágenes. Objetivos: Conocer el manejo y la evolución intrahospitalarios y a los 18 meses de la embolia pulmonar en el contexto de una endocarditis infecciosa asociada a marcapasos. Materiales y métodos: Búsqueda bibliográfica efectuada en PubMed. Relato del caso clínico: evaluación clínica, presentación de los estudios complementarios y tratamiento. Seguimiento del caso. Resultados: Paciente de 68 años, sexo femenino, con antecedente de implantación de marcapaso definitivo bicameral hace 2 años. Síndrome febril prolongado sin foco aparente, con hemocultivos que fueron positivos para Staphylococcus aureus meticilino-resistente. En el ecocardiograma transesofágico presentaba múltiples vegetaciones en aurícula derecha asociadas con los catéteres. Con base en la anamnesis, el examen físico y los hallazgos en exámenes específicos, se pudo lograr el diagnóstico de EI asociada a marcapasos. Se indicó tratamiento antibiótico y la remoción completa percutánea del dispositivo. Luego del procedimiento presentó disnea súbita confirmándose mediante estudio de centellograma ventilación-perfusión el diagnóstico de embolia pulmonar. Completó el tratamiento antibiótico (vancomicina durante 6 semanas) y fue dada de alta. Durante el seguimiento no presentó nuevas infecciones u otras complicaciones. Conclusión: En nuestro caso, la embolia pulmonar no generó modificaciones en la morbimortalidad intrahospitalaria ni en el seguimiento a 18 meses.

Introduction: One of the most feared infective endocarditis (IE) complications associated with pacemaker is pulmonary embolism. We present the case of a patient with a current diagnosis of pacemaker-associated IE who presented symptoms of pulmonary embolism confirmed by imaging studies after percutaneous removal of the device. Objectives: to know the management and evolution, in-hospital and at 18 months of pulmonary embolism in the context of infective endocarditis associated with pacemaker. Materials and methods: Bibliographic search carried out in PubMed. Clinical case report: clinical evaluation, presentation of complementary studies, and treatment. Follow up on the case. Results: 68-year-old patient with a history of dual chamber permanent pacemaker implantation 2 years ago. Prolonged febrile syndrome with no apparent focus, with positive blood cultures for methicillin-resistant Staphylococcus aureus. The transesophageal echocardiogram showed multiple vegetations associated in right atrial with the catheters. Based on the history, physical examination, and findings in specific tests, the diagnosis of IE associated with DEIP could be achieved. Antibiotic treatment and complete percutaneous removal of the device were indicated. After the procedure, he presented sudden dyspnea, confirming the diagnosis of pulmonary embolism in a ventilation-perfusion scintigram study. She completed the antibiotic treatment (vancomycin for 6 weeks) and was discharged. During follow-up, there were no new infections or other complications. Conclusion: in our patient pulmonary embolism did not generate changes in in-hospital morbidity and mortality or in the 18-month follow-up.

Endocarditis infecciosa y eritema multiforme minor

El eritema multiforme es una reacción inmunomediada que envuelve la piel y algunas veces a la mucosa. Las infecciones y medicamentos constituyen las causas más comunes. Típicamente se presenta como lesiones "en diana" sobreelevadas con centro pálido y borde eritematoso o lesiones atípicas como vesículas o ampollas. Se presenta el caso de una mujer de 68 años que acude por tumoración a nivel del antebrazo derecho con signos inflamatorios más fiebre, se constata por ecografía aneurisma micótico en dicho miembro y se realiza ecocardiografía transtorácica donde se observan vegetaciones en válvulas aortica y mitral. Durante la internación presenta aparición de lesiones ampollosas con bordes eritematosos distribuidas en tronco y brazos con biopsia que informa erupción liquenoide ampollosa compatible con eritema multiforme minor.

Erythema multiforme is an immune-mediated reaction that involves the skin and sometimes the mucosa. Infections and medications are the most common causes. Typically presents as raised "target" lesions with a pale center and erythematous border or atypical lesions such as vesicles or bullae. We present the case of a 68-year-old woman who presented with a tumor on the right forearm with inflammatory signs plus fever, a mycotic aneurysm was confirmed by ultrasound in the limb and a transthoracic echocardiography was performed where vegetations were observed on the aortic and mitral valves. During hospitalization, she presented bullous lesions with erythematous borders distributed on the trunk and arms with a biopsy that reported bullous lichenoid eruption compatible with erythema multiforme minor.

Double Outlet Right Ventricle Infective Endocarditis: A Rare Combination and a Therapeutic Challenge

Infective endocarditis involving the right side of the heart occurs rarely and often involves the tricuspid valve. The isolated pulmonary valve infective endocarditis (IPVIE) is a less common condition that occurs in specific population. The double outlet right ventricle (DORV) is an unusual congenital heart disease. The association of DORV and IPVIE darkens the prognosis. We report two cases of the association of DORV and IPVIE. The transthoracic echocardiography (TTE) is the base to the diagnosis. Right sided infective endocarditis in the lack of a guided strategy remains a therapeutic challenge.

Diagnostic Use of Serum Ferritin as a Predictor of Hospital Outcome at Admission in Patients with Infective Endocarditis

Background: Infective endocarditis (IE) is characterised by a concentration of infection inside the heart; it is caused by a bacterial or fungal infection of the endocardial surface of the heart; and it is linked with substantial morbidity and death.The aim of this research was to assess serum ferritin as an admission predictor of in-hospital prognosis in subjects with IE. Methods: This case control researchincluded60subjects diagnosed with IEon the basis of the modified duke's criteria.Subjects were allocated equally into two groups: group I: IE subjects who were further subdivided into two groups based on presence or absence of major adverse cardiovascular events (subgroup A: 19 patients who showed IE complications or major adverse cardiac events during hospitalization and subgroup B: 11 patients who showed a smooth course during hospitalization without major adverse cardiac events or IE complications) and IE subjects as well as age and sex matched 30 healthy subjects. Results: serum ferritin level were significantly increased in group I than group II (P value<0.05). Serum ferritin level was significantly increased in subgroup A than subgroup B (P value<0.001). serum ferritin can significantly predict bad outcome (P value<0.001) with AUC of 0.964 (95% CI: 0.881 – 0.995). At cut off >1200, serum ferritin can significantly predict bad outcome with 94.44% sensitivity, 92.86% specificity, 85% PPV and 97.5% NPV. Conclusions: Serum ferritin was significantly increased in IE subjects who experiencedproblems on admission as compared to IE subjects who didn’t.

Infective Endocarditis: Experience of the Cardiology Department of the Mohammed VI University Hospital

Introduction: Infective endocarditis (IE) is a rare but potentially serious disease. It causes a high mortality and a high level of morbidity and complications. Its epidemiological, clinical and microbiological characteristics have changed in recent years. The Aim of our Work: Is to study the epidemiological, clinical, bacteriological, ultrasonographic, therapeutic and evolutionary data of IE between January 2017 and October 2022 in the Mohammed VI University Hospital and to compare them to the global profile. Materials and Methods: Retrospective study including 110 patients hospitalized for a definite IE, according to the modified DUKE criteria, in the cardiology department of the Mohammed VI University Hospital over a period of 5 years and 10 months from January 2017 to October 2022. Results: The average age of our patients was 43 years with a male predominance. The bacterial graft was on native valve in 80% with predominance of rheumatic origin (69%), on cardiac prosthesis in 10% of patients, on healthy heart (4%) and congenital heart disease (6%). The most frequent portal of entry was dental (30%). Blood cultures were positive only in 33% of patients, isolating a staphylococcus (16%), a streptococcus (14%) and a GNB (3%). Transthoracic echocardiography (TTE) showed vegetation in 108 cases, valve perforation in 7 cases, cord rupture in 1 patient and perivalvular abscess in 10 cases. Seventy-seven percent of patients had surgical treatment with a mean delay of 29 days. The overall mortality was 24% with heart failure (p<0.001), renal failure (p=0.004) and neurological complications (p=0.002) as predictive factors of mortality. Conclusion: Infective endocarditis remains a real health problem with a consequent mortality and morbidity. The population is often young, revealing the IE by complications; its prevention is the best way to improve its prognosis.

Aorto-right Ventricular Fistula: A Rare and Severe Complication in a Young Patient with Double Localization of Infective Endocarditis

Aorto-right ventricular fistulas are defects of the aortic wall in the area above the right coronary cusp, where it separates aorta and right ventricular outflow tract. This entity is rare and exceptional. Often, these defects are due to trauma or infective endocarditis. We report an occasional finding of such a fistula with dramatic issue, in young patient without past medical history which admitted for rupture of cerebral mycotic aneurysm secondary to infective endocarditis with double localization (aortic and pulmonary valve).

Williams?Beuren Syndrome with Pseudoaneurysm of Aortic Arch and Infective Vegetations for Modified Broms Procedure: Anesthetic Concerns & Echocardiographic Illustrations

Williams?Beuren syndrome is a rare genetic malformation with predilection for supravalvular aortic stenosis. Apart from cardiovascular malformation, hypocalcemia, developmental delay, and elfin facies, challenging airway make perioperative management more eventful. Association of infective endocarditis within the aortic arch and pseudoaneurysm formation is infrequent. We, hereby report a case of pseudoaneurysm formation and infective vegetation within the aortic arch in a patient with Williams syndrome and the role of transthoracic echocardiography in its perioperative management.

Prevalencia de endocarditis infecciosa a partir de procedimientos odontológicos / Prevalence of infective endocarditis from dental procedures

Resumen Introducción: Los procedimientos dentales han sido asociados a bacteriemia y endocarditis infecciosa. Objetivo: Determinar la prevalencia de endocarditis infecciosa a partir de procedimientos odontológicos. Materiales y métodos: Se realizó un estudio descriptivo de tipo retrospectivo cuantitativo. Se incluyeron historias clínicas de pacientes con endocarditis infecciosa a los cuales se les registró identificación general, sexo, edad, estrato socioeconómico, reporte de procedimiento odontológico, tipo de procedimiento odontológico, endocarditis infecciosa no especificada y reporte de procedimiento médico-quirúrgico. Adicionalmente, se registró información sobre el tipo de procedimiento médico-quirúrgico o condición médica relacionada. Los datos fueron compilados en hoja de cálculo para su procesamiento en software estadístico (SPSS ver. 25). Resultados: De 154 casos de endocarditis infecciosa registrados, solo en uno (0.7%) se reportó procedimiento odontológico del tipo endodoncia previo a la hospitalización. La causa relacionada más comúnmente reportada fue cateterismo para hemodiálisis (37%) seguido de bacteriemia no específica (22%) y condición cardiovascular asociada a válvulas cardíacas y marcapasos (18.8%). En el 15.6% de los casos se reportó como endocarditis infecciosa no especificada. Los microorganismos más comúnmente aislados pertenecen al género Staphylococcus, seguido de Streptococcus. Conclusiones: La frecuencia de endocarditis bacteriana relacionada con procedimientos odontológicos fue menor del 1%. Los procedimientos médico-quirúrgicos siguen siendo la causa más común de endocarditis bacteriana.

Abstract Introduction: Dental procedures have been associated with bacteriemia and infective endocarditis. Objective: To determine the prevalence of infective endocarditis from dental procedures. Materials and methods: A descriptive, retrospective quantitative study was carried out. Records of infective endocarditis of which the general identification, sex, age, socioeconomic status, dental procedure report, type of dental procedure and non-specified infective endocarditis information was collected. Additionally, information was recorded on the type of medical/surgical procedure or medical condition that was associated. Categorical variables are presented as absolute and relative frequencies. The data were compiled in a spreadsheet for processing in statistical software (SPSS ver. 25). Results: Of the 154 cases of infective endocarditis registered, only 1 case (0.7%) reported an endodontic-type dental procedure prior to hospitalization. The most reported related cause was catheterization for hemodialysis (37%) followed by unspecified bacteriemia (22%) and cardiovascular condition associated with heart valves and pacemakers (18.8%). In 15.6% of the cases, it was reported as non-specific infective endocarditis. The most isolated microorganisms belonged to the genus Staphylococcus followed by Streptococcus. Conclusions: The frequency of bacterial endocarditis related to dental procedures was less than 1%. Medical-surgical procedures remain the most common cause of bacterial endocarditis.

A Life-Threatening Case of Infective Endocarditis Complicated by Destruction of the Aortic Valve and Embolism of the Left Anterior Descending Coronary Artery / 日本心臓血管外科学会雑誌

A 39-year-old man with fever and dyspnea from 3 days earlier was taken to the emergency room. He was diagnosed with infective endocarditis because echocardiography showed a mobile 10 mm-sized vegetation on the aortic valve and severe aortic regurgitation. Acute coronary syndrome was negative because the tests at the first visit did not show an increase in myocardial deviation enzymes or a decrease in wall motion. However, his hemodynamics deteriorated during the same day, so he underwent emergency surgery. The left and right leaflets and the right aortic annulus were highly destroyed, and the aortic annulus was reconstructed with his pericardium and the valve was replaced by a mechanical valve. After declamping of the aorta, the wall motion of the left ventricle was extremely reduced, and the cardiopulmonary bypass(CPB) was not able to be withdrawn. Since the left anterior descending (LAD) coronary artery may have been occluded by vegetation, we added bypass surgery to the LAD under cardiac arrest using a saphenous vein graft. After the bypass surgery, the wall motion of the left ventricle improved, and we were able to withdraw the CPB. Though he developed a cerebral infarction as a complication and required long-term rehabilitation, he was able to be discharged from the hospital 74 days after the operation. We evaluated the coronary arteries after his discharge and found an occlusion that was thought to be due to vegetation scattered in the LAD. No preoperative coronary artery evaluation was performed, however, the graft was anastomosed to the distal side of the LAD occlusion. Currently, 3 years and 2 months have passed and the infection has not recurred.

Acquired Left Ventricle to Right Atrial Communication Following Infective Endocarditis of the Native Aortic Valve Diagnosed Using Cardiac Computed Tomography / 日本心臓血管外科学会雑誌

Left ventricle to right atrial communication is a rare cardiac pathology, and it is either congenital or acquired. Recently, case reports of acquired left ventricle to right atrial communication have been increasing because of the increased numbers of cardiovascular procedures and improved cardiac diagnostic techniques. We report a case of acquired left ventricle to right atrial communication in a patient with native aortic valve infective endocarditis. A 52-year-old man with worsening dyspnea on exertion and lower leg edema was admitted to a hospital. Blood examination revealed elevated inflammatory marker levels, and transthoracic echocardiography (TTE) showed an aortic valve vegetation. The patient was subsequently transferred to our hospital for infective endocarditis with congestive heart failure. Medical treatment with antibiotics and diuretics was initiated. Cardiac computed tomography (CT) demonstrated left ventricle to right atrial communication. An urgent operation was performed wherein the defect was closed with autologous pericardial patches from both the right atrium and left ventricle. Aortic valve replacement was performed with a mechanical valve. The postoperative course was uneventful, and TTE showed no residual shunt. In our case, cardiac CT was useful for accurately diagnosing left ventricle to right atrial communication.

A Case of Renal Hemorrhage after Open Heart Surgery for Infective Endocarditis with Renal Infarction / 日本心臓血管外科学会雑誌

A 55-year-old woman with fever and consciousness disorder diagnosed as infective endocarditis was transported to our hospital. She had atopic dermatitis. A mobile vegetation at the mitral valve was revealed by the transesophageal echocardiography, and a computed tomography (CT) scan showed cerebral infarction, left renal infarction and suspected embolization of the vegetation. Streptococcus aureus was detected in the blood culture test. We conducted emergent surgery, mitral valve plasty was performed. On the second day after the operation, the hemoglobin began to decrease, and the hemodynamics became unstable. The contrast CT examination revealed arterial bleeding from the left kidney, which had an infarction before the operation. We performed emergent catheter liquid embolization for the superior polar branch of the left renal artery, and the hemodynamics improved thereafter. There has been no report of renal hemorrhage after cardiac surgery for infective endocarditis. This case reminded us that cardiac surgery for infective endocarditis may cause various complications of organs.

Endocarditis Infecciosa a hemocultivos y ecocardiograma negativos: ¿Con qué otra herramienta contamos? A propósito de un caso

La endocarditis infecciosa (EI) es una enfermedad frecuente, con elevada morbi-mortalidad, cuyo diagnóstico continúa siendo un desafío en la actualidad. El abordaje de la misma debe de ser realizado por un equipo multidisciplinario. La semiología, herramienta fundamental en la medicina clínica, juega un rol preponderante, nos permite mantener una alta sospecha diagnóstica a pesar de contar con estudios paraclínicos negativos. En estas situaciones han ganado importancia las nuevas técnicas de imagen como el PET-TC. Se presenta el caso de una mujer con cardiopatía predisponente en el que se llega al diagnóstico por PET-TC.

Infective endocarditis (IE) is a frequent disease, with high morbidity and mortality, whose diagnosis continues to be a challenge nowadays. The approach must be carried out by a multidisciplinary team. Semiology, a fundamental tool in clinical medicine, plays a preponderant role, allowing us to maintain a high diagnostic suspicion despite having negative paraclinical studies. In these situations, new imaging techniques such as PET-CT have gained importance. We present the case of a woman with predisposing heart disease in whom the diagnosis was made by PET-CT.

A endocardite infecciosa (EI) é uma doença frequente, com alta morbimortalidade, cujo diagnóstico continua sendo um desafio na atualidade. Sua abordagem deve ser realizada por uma equipe multidisciplinar. A semiologia, ferramenta fundamental na clínica médica, desempenha um papel preponderante, permitindo-nos manter uma elevada suspeição diagnóstica apesar dos estudos paraclínicos negativos. Nestas situações, novas técnicas de imagem como o PET-CT têm ganhado importância. Apresentamos o caso de uma mulher com cardiopatia predisponente cujo diagnóstico foi feito pelo PET-CT.

Pharmaceutical care for a case of infective endocarditis caused by Micrococcus luteus complicated with severe pneumonia / 中国药房

OBJECTIVE To provide ideas and reference for the treatment and pharmaceutical care of infective endocarditis （IE） caused by Micrococcus luteus complicated with severe pneumonia. METHODS The clinical pharmacist participated in the treatment of a patient with IE caused by M. luteus complicated with severe pneumonia； all anti-infective treatment plans were agreed upon after the doctor invited the clinical pharmacist for consultation. After the implementation of the plan， the clinical pharmacist conducted pharmaceutical care of effectiveness and safety for the plan， including adopting suitable drug， adjusting the dose of vancomycin by using parameters such as steady-state valley concentration and creatinine clearance rate， monitoring renal function and adverse drug reactions. RESULTS IE caused by M. luteus was cured after surgery and full treatment with anti-bacterial drugs， the severe pneumonia was improved， and the decline of renal function caused by drugs and the primary disease were recovered； clinical pharmacists had ensured the effect of anti-infection treatment by assisting in the formulation of treatment plans and the implementation of pharmaceutical care， avoiding further renal damage and solving the problem of cefoperazone sulbactam- related drug fever. CONCLUSIONS IE caused by M. luteus is relatively serious， and the treatment drug can be vancomycin and rifampicin. During the treatment， it is necessary to monitor the renal function， and adjust the dose of vancomycin or change other drugs； anti-infection pharmaceutical care provided by clinical pharmacists can guarantee the effectiveness and safety of anti- infection plan， and avoid the occurrence of severe adverse drug reactions.

Granulicatella adiacens, the Elusive Endocarditis Causative Agent: Highlighting the Challenges Faced by Microbiology Laboratory

@#A 58-year-old man with history of mitral valve prolapse and previous motor vehicle accident presented with one week history of lower back pain and fever. He was initially treated for pyelonephritis and given ceftriaxone. Blood culture grew Granulicatella adiacens after 7 days of incubation. The laboratory then referred the case to infectious disease team in view of possible infective endocarditis. Urgent echocardiogram was done and confirmed the diagnosis. His antibiotic was changed to intravenous benzylpenicillin and gentamicin. Granulicatella adiacens are difficult to be isolated in the laboratory hence they imposed certain challenges in laboratory identification. Most patients with Granulicatella adiacens infective endocarditis present with non-specific symptoms, imposing further challenge in recognizing the condition. These factors posed significant challenges in diagnosing Granulicatella adiacens endocarditis. This case highlighted challenges faced by the laboratories and the need of high index of clinical suspicion and prompt communication to ensure optimum patient care and management.

Antibiotic Prophylaxis Before Invasive Dental Procedures for Patients atHigh Risk of Infective Endocarditis - A Systematic Review

Background: Clinical use of antibiotics prophylaxis (AP) for preventing infective endocarditis (IE) after invasive dental procedures is controversial. Expert consensus guidelines are inconsistent, either restricting its use to high?risk individuals or advising its use again. Objectives: To determine whether there is a genuine need for AP to prevent IE in high?risk patients undergoing invasive dental procedures. Methods: Online search was performed on PubMed, Science Direct, British Dental Journal and Cochrane Register of Controlled Trials. The methodological quality of each study was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. Results: Seventeen (17) clinical trials were included in the final analysis recruiting 2,410 patients (AP = 1,366; placebo = 1,044). Bacteraemia was detected in 302 AP patients (22.1%) and 362 placebo patients (34.7%). AP reduced the risk of bacteraemia by 49% (risk ratio: 0.51; 95% CI; 0.45 to 0.58; P = 0.0001). Conclusion: Although using AP for IE may be pragmatic and justified for high?risk patients undergoing invasive dental procedures, the evidence is inconclusive because post?procedural bacteraemia may not be a good surrogate marker for IE. Moreover, trials investigating the direct association between AP and IE are lacking due to low disease prevalence and high?cost challenges

Perioperative Management of Patients with Prosthetic Heart Valves?A Narrative Review

Worldwide, about 13% of the 200,000 annual recipients of prosthetic heart valves (PHV) present for various surgical procedures. Also, more and more females are opting for pregnancies after having PHV. All patients with PHV present unique challenges for the anesthesiologists, surgeons and obstetricians (in case of deliveries). They have to deal with the perioperative management of anticoagulation and a host of other issues involved. We reviewed the English language medical literature relevant to the different aspects of perioperative management of patients with PHV, particularly the guidelines of reputed societies that appeared in the last 20 years. Regression of cardiac pathophysiology following valve replacement is variable both in extent and timeline. The extent to which reverse remodeling occurs depends on the perioperative status of the heart. We discussed the perioperative assessment of patients with PHV, including focused history and relevant investigations with the inferences drawn. We examined the need for prophylaxis against infective endocarditis and management of anticoagulation in such patients in the perioperative period and the guidelines of reputed societies. We also reviewed the conduct of anesthesia, including general and regional anesthesia (neuraxial and peripheral nerve/plexus blocks) in such patients. Finally, we discussed the management of delivery in this group of high?risk patients. From the discussion of different aspects of perioperative management of patients with PHV, we hope to guide in formulating the comprehensive plan of management of safe anesthesia in such patients.

Epidemiological Profile of Patients with Infective Endocarditis at three Tertiary Centers in Brazil from 2003 to 2017

Abstract Background Infective endocarditis (IE) is a disease with high morbimortality and an increasing incidence. With improved diagnosis and treatment, a number of epidemiological changes have been reported over time. Objectives We sought to describe the epidemiological profile, mortality predictors, and analysis of a possible microbiological transition in patients admitted to three tertiary centers in Brazil. Methods In this cross-sectional retrospective study, data from 211 patients with definite or probable IE were analyzed according to the modified Duke criteria between 2003 and 2017. The association between categorical variables was assessed using the chi-square or Fisher's exact test, and binary logistic models were built to investigate mortality. We considered p <0.05 statistically significant. Results The median age of the sample was 48 (33-59) years old, 70.6% were men, and the most prevalent pathogen was Staphylococcus spp. (19%). Mortality was 22.3%, with increasing age being the leading risk factor for death (p = 0.028). Regarding the location of the disease, native valves were the most affected site, with the aortic valve being more affected in men than women (p = 0.017). The mean number of cases of Staphylococcus spp. (τ = 0.293, p = 0.148) and Streptococcus spp. (τ = -0.078, p = 0.727) has remained stable over the years. Conclusion No trend towards reduced or increased mortality was evident between 2003 and 2017. Although Staphylococcus spp. were the most prevalent pathogen, the expected epidemiological transition could not be observed.