Risk for infective endocarditis in bacteremia with Gram positive cocci.

PURPOSE: Infective endocarditis (IE) is a serious complication of bacteremia and is most often caused by Gram positive cocci. We investigated the prevalence of IE in patients where echocardiography was encouraged when bacteremia with Gram positive cocci was present. METHODS: The study included patients with Gram positive cocci bacteremia hospitalized at two Danish hospitals between March and December 2016. Information concerning echocardiography, demographics and bacterial species was collected from the patients' medical files. Patients without echocardiography were followed for 6 months in order to confirm or reject possible IE. RESULTS: The study included 585 patients with Gram positive cocci bacteremia, and echocardiography was performed in 414 (71%) of them. The prevalence of IE in patients with high risk bacteremia, i.e. Staphylococcus aureus, non-beta-hemolytic streptococci, Enterococcus faecalis, and coagulase-negative staphylococci was 16%. Patients with Enterococcus faecalis had the highest prevalence of IE (33%) followed by non-beta-hemolytic streptococci (23%) and Staphylococcus aureus (12%). Among low risk bacteremia the prevalence of IE was 1%. The mean age of patients with IE was 74 years (SD 12.9) and 71% were male. CONCLUSION: These findings strongly support routine echocardiography in patients with high risk bacteremia and non-performance of echocardiography in patients with low risk bacteremia.

Clinical usefulness of FDG-PET/CT for identification of abnormal extra-cardiac foci in patients with infective endocarditis.

The aim of the study was to evaluate the ability to detect extra-cardiac foci by means of whole-body 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in patients with definite endocarditis (IE) according to the modified Duke criteria and investigate the clinical impact of the findings. From January 2011 to December 2015 we included 178 patients (mean age 66 ± 14 years, 25% female) with IE in this multicentre study. FDG-PET/CT was part of the work-up for extra-cardiac foci in the including hospitals and was performed at a median of 9 days (IQR 10) after IE was diagnosed. In 114 patients FDG-PET/CT identified 166 lesions: 52 (31%) infectious lesions, 21 (13%) cases of cancer, 7 (4%) cases of embolism, 60 (36%) reactive findings, and 26 (16%) other types of lesions. A total of 74 new extra-cardiac findings, not previously discovered by other modalities, were identified in 62 patients and resulted in additional investigations in 29 patients and a change in treatment in 18 patients (10%). The most frequent diagnoses discovered by FDG-PET/CT were colon polyps, cancer, and spondylodiscitis. There was a higher rate of findings leading to a change in treatment in patients above 67 years of age infected with other bacterial aetiologies than streptococci. FDG-PET/CT was useful to detect extra-cardiac foci. FDG-PET/CT findings may lead to unnecessary investigations. One out of 10 the patients with definite endocarditis had underwent a change in treatment regimen based on the FDG-PET/CT findings.

Increased Risk of Ischemic Stroke After Treatment of Infective Endocarditis: A Danish, Nationwide, Propensity Score-Matched Cohort Study.

BACKGROUND: Several studies have reported a high risk of ischemic stroke (IS) during the acute phase of infective endocarditis (IE). The long-term risk of IS after IE, however, is not fully illuminated. METHODS: This Danish, nationwide, register-based, propensity score-matched cohort study used Cox regression to estimate hazard ratios (HRs) of IS for persons with vs without a history of left-sided IE, from 1977 to 2015. RESULTS: We followed 9312 patients exposed to a first-time IE and 91 996 nonexposed, matched control persons. Compared to persons without IE, patients with a history of IE had a significantly increased risk of IS; the risk was highest during the first 4 weeks after IE diagnosis (HR 57.20, 95% confidence interval [CI] 45.58-71.78; P < .0001) and a moderately elevated risk persisted until 2 years after IE (4 weeks to 3 months after IE, HR 5.40, 95% CI 4.11-7.19; 3 months to 2 years after IE, HR 1.73, 95% CI 1.48-2.01). Mediation analyses showed that the higher risk of IS the first 2 years after IE could not be explained by atrial fibrillation (AF) or inserted mechanical valves in IE patients. In the period from 4 weeks to 3 months after IE diagnosis, patients treated with anticoagulative therapy had a lower risk of IS (HR 0.30, 95% CI .10-0.96; P = .04). CONCLUSIONS: Patients with a history of IE had an increased risk of IS for up to 2 years after IE diagnosis. The increased risk was unrelated to AF and inserted mechanical valves. During the initial phase after IE, patients taking an anticoagulative medication had a lower risk of IS.

In-hospital metabolite changes in infective endocarditis-a longitudinal 1H NMR-based study.

Treatment of infective endocarditis (IE) is a 4-6-week provided course of intravenously administered antibiotics. The aim of this study was to investigate how serum metabolites as measured by proton nuclear magnetic resonance (1H NMR) spectroscopy are changing over time during the active phase of IE, and to see whether these metabolite changes might be used to monitor recovery in these patients. Patients hospitalized with first-time IE at Herlev Hospital, Denmark, from September 2015 to June 2017 were included. Longitudinal blood sampling was performed and serum was analyzed using 1H NMR. Orthogonal projection to latent structures discriminant analysis (OPLS-DA) was used to separate sample groups and analyze differences in metabolite profiles. Thirteen patients were included in the study (77% men, median age 62 years (IQR 53-77)). All patients were cured during the hospitalization without any relapse during 6 months of follow-up. We analyzed 61 serum samples (median 5 samples, range 2-8 per person) drawn in the treatment period after IE diagnosis. The main changes during the in-hospital period were decreased levels of glucose, mannose, leucine, isoleucine, phenylalanine, tyrosine, and signals from polyols and N-acetylated protein. The metabolomic changes could in contrast to the routinely used parameters CRP and leucocyte levels distinguish between the early and late stages of disease treatment. We present the first longitudinal study of 1H NMR metabolomics in patients with infective endocarditis. The metabolomic changes show a promising strength compared to routinely used clinical parameters.