Risk assessment for infected endocarditis in Staphylococcus aureus bacteremia patients: When is transesophageal echocardiography needed?

AIMS: Echocardiography is the main technique for the diagnosis of endocarditis in patients with Staphylococcus aureus bacteremia (SAB), but a consensus about performing transthoracic echocardiography or transesophageal echocardiography (TEE) as first-line tests is currently lacking. Recently, a new scoring system has been proposed by Palraj et al. to guide the use of TEE in this population. Our aim was to validate this scoring system or modify it, if necessary. METHODS AND RESULTS: Data from SAB patients admitted from 2012 to 2014 were collected. We tested the Palraj scores to stratify patients' risk for endocarditis. Moreover, we analyzed our population to identify any other possible clinical predictors of endocarditis not included in the score. Endocarditis was diagnosed in 38 of 205 patients (18.5%). Palraj's score was effective in the detection of patients at high risk of endocarditis. In addition, we identified the presence of cardiac devices, prolonged bacteremia and intravenous drug abuse (IVDA) as elements strongly correlated with endocarditis. Two scoring systems (Day-1 and Day-5) were derived including IVDA as a variable. Using a Day-1 cut-off value ≥5 and a Day-5 cut-off value ≥2, the 'modified Palraj's score' showed sensitivities of 42.1% and 97.0% and specificities of 88.6% and 32.0% for Day-1 and Day-5 scores, respectively. CONCLUSION: We modify and expand upon an effective scoring system to identify SAB patients at high risk for endocarditis in order to guide use of TEE. The inclusion of IVDA in the criteria for the calculation of the scores improves its effectiveness.

Endocarditis in Greenland with special reference to endocarditis caused by Streptococcus pneumoniae.

OBJECTIVES: The aim of this retrospective study was to determine the incidence and outcome of infectious endocarditis in Greenland with an emphasis on pneumococcal endocarditis. STUDY DESIGN: Retrospective, non-interventional study. METHODS: Review of files and medical history of all patients with infectious endocarditis from the Patient Registry in Greenland in the 11-year period 1995-2005. RESULTS: There were 25 cases of endocarditis, giving an incidence rate of 4.0/100,000 per year. Twenty-four percent of these cases were caused by Streptoccous pneumonia, which is significantly more frequent than in studies on Caucasian populations, where pneumococcal infection was seen in 1-3% of endocarditis cases. The overall mortality rate was 12%. Pneumococcal endocarditis (PE) had the clinical characteristics of fulminant disease with frequent heart failure, complications and need for surgery. Among cases with PE, 67% needed acute valve replacement and the mortality rate was 33%. CONCLUSIONS: The high incidence rate, clinical characteristics and grave prognosis of PE are consistent with another study of an Inuit population in Alaska.

Epidemiologic features of infective endocarditis in Taiwanese adults involving native valves.

Little is known about the incidence and clinical outcomes of infective endocarditis (IE) involving native valves in Asian countries. This nationwide study investigated epidemiologic features and in-hospital mortality associated with IE in adults (age > or =18 years) based on Taiwan's National Health Insurance database from 1997 through 2002. Of 7,240 enrolled patients with IE involving native valves, the mean age was 53 +/- 19 years and 70% were men. The mean annual crude incidence was 7.6 per 100,000 inhabitants. The incidence was significantly higher in men than in women (10.4 vs 4.6 per 100,000; p <0.001). The incidence of IE increased steadily with age, ranging from 3.8 per 100,000 persons in patients <30 years of age to 33 per 100,000 persons in patients > or =80 years of age (p <0.001). Staphylococcal (32%) and streptococcal species (61%) were the most common causative pathogens. The mean in-hospital mortality rate was 18%. Multivariate analysis showed that male gender, older age (> or =50 years), diabetes mellitus, heart failure, neurologic complications, renal insufficiency, respiratory failure, shock, and Staphylococcus species as the causative microorganism were independent predictors of in-hospital mortality. In conclusion, this Taiwanese study revealed a high incidence of IE in men and elderly subjects. The in-hospital mortality rate remained high. Patients with IE who also developed shock and respiratory failure were the most likely to have a poor outcome.

[The acquired immunodeficiency syndrome, hypertrophic myocardiopathy and multivalvular infectious endocarditis. Apropos a clinical case]. / Síndrome de imunodeficiência adquirida, miocardiopatia hipertrófica e endocardite infecciosa multivalvular. A propósito de um caso clínico.

We present a clinical case of a 33 years old young male, gypsy, intravenous drug abuser with heroine and cocaine and AIDS diagnosis. The clinical anamnesis was mainly fever and systolic heart murmur in a clinical scenario of AIDS. The two-dimensional echocardiographic study was clearly diagnostic of an hypertrophic obstructive cardiomyopathy of the left ventricle. This study showed also the presence of multiple vegetations of the mitral, aortic and pulmonic valves in a clinical setting of an acute Streptococcus Viridans infective endocarditis. In this case report we discuss the incidence of this type of multiple cardiac lesions and particularly the presence of this specific pathogenic agent in this high risk group of patients with intravenous drug abuse and systemic immunosuppression. We pointed out the rarity of these findings of left side valvular vegetations associated with this type of cardiomyopathy and the different factors related to infective endocarditis.

Isolated right-sided endocarditis in Hong Kong Chinese.

Thirteen histologically-proven cases of endocarditis confined to the right side of the heart were found in 9406 consecutive autopsies. Eleven cases involved the tricuspid valve and two the atrial endocardium. Nine cases were in males and 4 in females. Only one case showed underlying valvular/endocardial disease. Eight cases were infective, with Staphylococcus aureus being the predominant organism, and 5 non-infective. For the infective cases, intravenous drug abuse was the commonest predisposing factor, and malignancy the commonest association for the non-infective. The commonest overall complication was lung abscess due to septic emboli in the 3 drug addicts, a common association in other reported series. These latter cases are particularly important to recognize, being generally more responsive to treatment than left-sided infective endocarditis.

Pneumococcal endocarditis in Alaska natives. A population-based experience, 1978 through 1990.

BACKGROUND: Streptococcus pneumoniae is an uncommon cause of infective endocarditis (IE). We studied the presentation, microbiologic characteristics, and outcome of nine cases of S pneumoniae IE during a 12 1/2-year period in a population of 75,000 indigenous Alaska Natives (ANs), who have documented high rates of invasive pneumococcal disease. METHODS: Fifty-six cases of IE occurred in ANs statewide during 1978 through 1990. Medical records of all nine confirmed cases of S pneumoniae IE were reviewed. Incidence rates for S pneumoniae IE and all IE were calculated. RESULTS: Alaska Natives experience S pneumoniae IE as a fulminant illness, with acute aortic valve insufficiency (100%) frequently requiring emergent valve replacement, S pneumoniae meningitis (56%), and death (33%). No patient with S pneumoniae IE had known preexisting heart disease, and the most common underlying disease was alcoholism (56%). Pneumonia was diagnosed and embolic complications were suspected in 33%. All five S pneumoniae isolates examined were penicillin sensitive and were of serotypes included in the pneumococcal vaccine. Pneumococcal IE accounted for 15.8% of all IE diagnosed in ANs. Age- and sex-adjusted incidence rates for IE of all causes and S pneumoniae IE were 8.5 and 1.5 per 10(5) persons per year, respectively. During 1986 through 1988, 4.3% of AN adults diagnosed with S pneumoniae bacteremia developed S pneumoniae IE. CONCLUSIONS: Pneumococcal endocarditis in all but one AN case required emergent valve replacement and had a 33% mortality. The annual incidence rate of S pneumoniae IE in this population was five to 37 times higher than contemporary rates elsewhere. Increased efforts to prevent pneumococcal disease in ANs appear warranted. Clinicians everywhere should anticipate the possible development of S pneumoniae IE in adult patients with pneumococcal sepsis, especially with meningitis, even with previous vaccination and prompt adequate antimicrobial therapy.

Infective endocarditis in black South African children: report of 10 cases with some unusual features.

Ten black South African children with infective endocarditis seen over a 2-year period are reported. In five cases, including two neonates, the infection was nosocomial and in five cases it occurred in children with previously normal hearts. Of the bacteria isolated from nine cases, five were Staphylococcus aureus (all from nosocomial cases), one was Haemophilus influenzae and three were corynebacteria. The unusual aspects of this series are discussed, with an emphasis on preventing nosocomial cases and on making the diagnosis in children without underlying heart disease.