Infective endocarditis: prevention, diagnosis, treatment, referral.

Infective endocarditis is a challenge to the primary care physician, who is not likely to see more than several cases a year. With proper diagnosis and treatment, the overall cure rate is over 80% and major complications such as congestive heart failure can be avoided. In some patients, even in some with acute infection, surgical intervention to restore cardiac function significantly improves the outcome. Guidelines for prophylaxis before various surgical procedures are presented.

Comparing physician-specific two-year patient outcomes after coronary angiography: methodologic issues and results.

OBJECTIVES: We sought to evaluate methodologies to compare physician-related long-term patient outcomes appropriately. BACKGROUND: Evaluation of physicians on the basis of short-term patient outcome is becoming widely practiced. These analyses fail to consider the importance of long-term outcome, and methods appropriate to such an analysis are poorly defined. METHODS: All patients undergoing coronary angiography between 1992 and 1994 who received all of their cardiac care at our institution were followed for 27+/-13 months (mean+/-SD). Patients (n = 754) were cared for by one or more of 17 staff physicians. Risk-adjusted models were developed for four candidate clinical end points and cost. Physicians were then evaluated for each outcome measure. RESULTS: Of the clinical end points, death could be modeled most accurately (c-statistic = 0.83). The c-statistics for other end points ranged from 0.63 to 0.70. Physicians with outcomes statistically different (p < 0.05) from other physicians were identified more commonly than would be expected from the play of chance (p = 0.005). However, improvement in the c-statistics by the addition of physician identifiers was very modest. Physician's evaluations by the four measures of clinical outcome were variably correlated (r = .00 to .85). Graphic display of clinical and cost results for each physician did identify certain physicians who might be judged to provide more cost-effective care than others. CONCLUSIONS: Although comparisons of groups of physicians on the basis of long-term patient outcomes may have merit, individual physician-to-physician comparisons will be more difficult, owing to 1) multiple physicians contributing care to individual patients; 2) the poor predictive capacity of models other than that for survival; and 3) the modest apparent impact of differences in physician providers on long-term patient outcome. With these caveats in mind, modeling to compare patient outcomes of individual physicians with homogeneous patient populations or to identify gross outliers (good or bad) may be practicable in some patient-care systems, but may be inappropriate in others.

Secular trends in nosocomial bloodstream infections in a 55-bed cardiothoracic intensive care unit.

BACKGROUND: Although bloodstream infections (BSIs) occur more frequently in intensive care unit patients than in ward patients, most studies of nosocomial BSIs in critically ill patients have not distinguished between intensive care unit populations beyond surgical, medical, and pediatric patients. METHODS: The primary objective of this study was to characterize the secular trends in rates of nosocomial BSIs for all pathogens among patients admitted to a busy cardiothoracic intensive care unit in a single tertiary care institution between January 1986 and December 1995. Patients with nosocomial BSIs were identified through continual prospective surveillance. RESULTS: A total of 40,207 patients were admitted to the cardiothoracic intensive care unit during the 10-year study period, and 804 episodes of nosocomial BSIs among 681 patients were identified. The mean crude BSI infection rate was 6.0 per 1,000 patient-care days and increased linearly during the study period (range, 4.4 to 8.1 per 1000 patient-care days), and approached statistical significance (p value = 0.07). The most common organisms causing BSIs were Staphylococcus aureus (12%), coagulase-negative staphylococci (11%), Candida albicans (11%), Pseudomonas aeruginosa (10%), and Enterococci (9%). The leading sources of nosocomial BSIs were primary BSIs (33%), intravascular devices (27%), lower respiratory tract infections (17%), and surgical wound infections (12%). The etiologic fraction or the proportion of deaths in cardiothoracic intensive care unit patients with BSIs was 15-fold higher than those patients without BSIs (37% versus 2.5%, p < 0.001). CONCLUSIONS: Rates of nosocomial BSIs among patients in our cardiothoracic intensive care unit have increased linearly during the past decade and patients with nosocomial BSIs have an increased risk of in hospital mortality.

Fungal prosthetic valve endocarditis in 16 patients. An 11-year experience in a tertiary care hospital.

Fungal prosthetic valve endocarditis (PVE) is an infrequent but serious complication of valve replacement surgery. To examine its long-term outcome, we retrospectively studied 16 patients with 19 episodes of definite fungal PVE. The mean age was 51 years (range, 27-71 yr). Onset of fungal PVE ranged from 8 days to 3.4 years after valve replacement. Candida albicans was the most common (56%) pathogen isolated. A portal of entry was identified in only 25% of the patients; the presence of intravascular catheters (50%) and prior bacterial endocarditis (38%) were leading predisposing factors. Fever (83%) was the most consistent clinical finding. Potentially serious embolic events, particularly strokes (32%), were common at presentation. Transesophageal echocardiography (sensitivity = 100%) was more useful than transthoracic echocardiography (sensitivity = 60%) in detecting lesions due to fungal PVE. Combined valve replacement surgery and amphotericin B (mean total dose of 1.8 g) in 15 patients resulted in an 87% in-hospital survival and 67% overall survival with a mean follow-up of 4.5 years (range, 5 mo to 16 yr). Two patients had 3 late relapses of fungal PVE up to 9 years after the preceding episode. Each relapse was treated with repeat valve replacement and amphotericin B; in addition, oral azole was utilized for chronic suppression, although the efficacy of this strategy remains unproven. Because of the possibility of relapse, long-term follow-up is essential even after surgical and prolonged antifungal therapy.

Pott's puffy tumor due to Haemophilus influenzae: case report and review.

Osteomyelitis of the frontal bone may be associated with a purulent collection under the periosteum, causing swelling and edema over the forehead, a condition known as Pott's puffy tumor. We describe an 83-year-old man with a Pott's puffy tumor due to Haemophilus influenzae that was successfully treated with surgery and antibiotics. A review of 22 cases of Pott's puffy tumor shows that this condition usually occurs in children, is spread from frontal or ethmoid sinusitis, and is usually due to streptococci, staphylococci, or anaerobes. Suppurative complications such as epidural, subdural, and intracerebral abscesses are common. Only seven cases of Pott's puffy tumor in adults have been reported, and only one of these cases was caused by H. influenzae. Surgical drainage and antibiotic therapy remain standard therapy for this condition.

Impact of a gonorrhea control program, including selective mass treatment, in female sex workers.

A gonorrhea control program initiated in 1967 in registered female sex workers (FSWs) in the Philippines involved weekly endocervical cultures for Neisseria gonorrhoeae, with treatment of FSWs found infected or named as contacts by US Navy servicemen. Gonorrhea prevalence in FSWs in Olongapo city fell from 11.9% to 4.0% within 4 months, and gonorrhea incidence in servicemen at nearby Subic Bay fell by half. Selective mass treatment (SMT) with oral ampicillin-probenecid or tetracycline was then given to registered FSWs in an attempt to further reduce gonorrhea rates. N. gonorrhoeae was isolated from 105 (4.0%) of 2640 FSWs before SMT and from 43 (1.6%) 1 week later (P < .001). However, gonorrhea incidence among servicemen fell no lower, and gonorrhea prevalence in FSWs quickly returned to higher levels. Thus, after implementation of weekly screening and treatment of FSWs found infected or named as contacts, SMT of FSWs (without increasing condom use or treating regular partners) contributed nothing further to gonorrhea control.

Early infectious complications in autologous bone marrow transplantation: a review of 219 patients.

The objective of this study was to define the incidence, type and timing of early infectious complications, occurring within the first 30 days, in autologous bone marrow transplant (autoBMT) recipients over a 45-month period, and in addition to assess the effects of growth factors and primed peripheral blood progenitor cells on the rate of infectious complications. The paper describes a retrospective and observational study, carried out at the bone marrow transplantation unit at a tertiary referral center. The subjects were two hundred and nineteen patients who underwent autologous bone marrow transplantation for a variety of indications from April 1989 to December 1992. The median duration of neutropenia after autologous bone marrow transplantation was 12 days. There was a direct correlation between the duration of neutropenia and the incidence of infectious complications. The overall incidence of infections and isolated febrile episodes was 35%. Septicemia occurred in 7.8% of patients, pneumonia in 2.7%, skin infection in 1.8%, other infections in 2.7% and isolated febrile episodes in 20.1%. Viridans streptococci were the most common cause of septicemia. Invasive fungal infections occurred in only 2.3% of patients. There were no documented viral infections. The use of growth factors and primed peripheral blood progenitor cells was associated with a shorter duration of neutropenia; a decrease in the overall incidence of infections, particularly septicemia and fungal infections; a shorter length of stay in the hospital and a lower mortality rate in the first 30 days after transplantation. We found a lower incidence of bacterial and fungal infections compared to previous studies. The critical factor associated with the occurrence of any early infection was the duration of neutropenia, which was significantly shortened by the use of growth factors and peripheral blood progenitor cells. Septicemia was uncommon in our population and viridans streptococci were the most common bloodstream isolates.

The clinical usefulness of the preoperative bleeding time.

OBJECTIVES: To determine the clinical utilization of the Simplate bleeding time test as a preoperative screen, to examine the clinical utilization of the bleeding time test by multiple surgical services, and to correlate the indicators of bleeding risk (bleeding history, thrombocytopenia, prolonged prothrombin time/activated partial thromboplastin time, increased creatinine, and medications known to interfere with platelet function) with the bleeding time and the occurrence of clinically significant perioperative bleeding. DESIGN: Retrospective data analysis. SETTING: A large tertiary-care hospital. PATIENTS: One hundred sixty-seven consecutive surgical patients tested for preoperative bleeding time. MAIN OUTCOME MEASURES: The occurrence of clinically significant perioperative bleeding and the positive and negative predictive value of the preoperative screening bleeding time test. RESULTS: Patients with a positive bleeding history were more likely to have an abnormal bleeding time (P = .04), but there was no statistically significant association between patients with an abnormal bleeding time and the other indicators of bleeding risk examined or the occurrence of clinically significant perioperative bleeding. The positive predictive value of the preoperative bleeding time was 5%, and the negative predictive value was 95%. CONCLUSIONS: Screening for preoperative bleeding time is not a reliable test for assessing the risk of clinically significant perioperative bleeding and should not be used for this purpose.

Candida prosthetic valve endocarditis: prospective study of six cases and review of the literature.

Candida prosthetic valve endocarditis (PVE) is a rare entity; however, its incidence is expected to increase given the recent increase in incidence of nosocomial bloodstream candida infection. This report reviews six cases of candida PVE studied prospectively plus 12 cases previously reported in the literature. Transesophageal echocardiography was more sensitive than transthoracic echocardiography in detecting vegetations. Valvular replacement combined with antifungal therapy has been the standard treatment. However, successful therapy with long-term administration of oral fluconazole has been reported for five patients. The mortality due to candida PVE was high, especially when PVE was complicated by congestive heart failure and persistent fungemia. For uncomplicated PVE, the mortality rate for patients receiving antifungal therapy alone (40%) was no worse than for those receiving combined medical and surgical therapy (33%).

Implantable LVAD infections: implications for permanent use of the device.

BACKGROUND: Infection in implantable left ventricular assist device (LVAD) patients is common and has serious implications regarding permanent use of the LVAD. METHODS: Thirty-three patients had HeartMate LVAD insertion as a bridge to heart transplantation. The mean length of hospital stay was 8 days before LVAD insertion. Before insertion 6 patients (18%) had positive pulmonary cultures and 5 patients (15%) had bacteremia. RESULTS: During LVAD support 18 patients (55%) had bloodstream infection. Of 24 patients (73%) successfully bridged to transplantation, 12 (50%) had positive blood cultures including Staphylococcus species (n = 9), Candida (n = 3), Pseudomonas (n = 2), and Enterococcus (n = 2). Infectious complications encountered in this series included driveline infection requiring surgical revision, septic embolus, "cleared" device infection, "suppressed" device infection, and LVAD infection treated by device removal in 1 patient and device exchange in another. CONCLUSIONS: Infection in implantable LVAD patients is common, especially in patients in whom multiple organ failure develops, requiring prolonged stay in the intensive care unit. Strategies are needed to prevent these infections in recipients of the permanent LVADs because treatment of an established infection is difficult and expensive.

Bloodstream infections in patients with implanted prosthetic cardiac valves.

A bloodstream infection in a patient with a recently implanted prosthetic cardiac valve is an ominous sign. In the six studies reviewed, the overall mortality rate for patients with bloodstream infections with and without prosthetic valve endocarditis (PVE) were 48% and 51%, respectively. Patients with PVE usually die from a complication of endocarditis. The high mortality rate in patients without endocarditis can be attributed to a severely ill cohort of hospitalized patients, who have a prolonged postoperative course and require life support in intensive care units for multiple organ failure. Although gram-positive cocci (especially coagulase-negative staphylococci) are the most common organisms associated with PVE, any microorganism isolated from the bloodstream must be considered as a potential cause of endocarditis in patients with prosthetic cardiac valves. The conclusion of earlier studies, that PVE was unlikely if infection was due to a gram-negative aerobic bacillus or if a portal of entry could be established, has not been supported by recent studies. An aggressive search for evidence of endocarditis must be performed in all patients with implanted heart valves and bloodstream infections. Successful treatment for most cases of early-onset PVE is primarily surgical.

Prosthetic valve endocarditis: superiority of surgical valve replacement versus medical therapy only.

The objective of our study was to assess the long-term outcome of patients with prosthetic valve endocarditis. We used a multicenter, prospective, observational study design. Six university teaching hospitals with high volume cardiothoracic surgery participated. Seventy-four patients with prosthetic valve endocarditis as defined by explicit, objective criteria were selected for participation. All patients were followed up prospectively for 1 year. Thirty-one percent and 69% had development of endocarditis within 60 days of valve insertion ("early") and after 60 days ("late"), respectively. The most common causes were Staphylococcus epidermidis (40%), Staphylococcus aureus (20%), streptococcal species (18%), and aerobic gram-negative bacilli (11%). Physical signs of endocarditis (new or changing murmur, stigmata, emboli) were seen in 58%. At 6 months and 12 months, mortality was 46% and 47%, respectively. Surgical replacement of the infected valve led to significantly lower mortality (23%) as compared with medical therapy alone (56%), as assessed by both univariate and multivariate analyses (p < 0.05). Improved outcome was seen for the surgical group even when controlling for severity of illness at time of diagnosis. From these findings we conclude that accurate assessment of outcome in prosthetic valve endocarditis requires long-term follow-up of at least 6 months following diagnosis. Surgical therapy warrants greater scrutiny; evaluation in controlled clinical trials is appropriate.

Early-onset prosthetic valve endocarditis.

BACKGROUND: Endocarditis following cardiac valve implantation is a rare but serious complication. OBJECTIVE: To determine the risk and outcome of early-onset prosthetic valve endocarditis (EO-PVE) in adult patients at The Cleveland Clinic. METHODS: Retrospective review of a 5-year case series of patients who acquired bloodstream infections within 60 days of surgery identified through a prospective surveillance program. RESULTS: Sixty-eight of approximately 2100 patients acquired bloodstream infections; 16 (24%) contracted EO-PVE and 52 (76%) did not. Risk factors for EO-PVE included younger age, at least three sets of positive blood culture results, and an organism other than a gram-negative bacillus. The majority of patients with EO-PVE had a recognized source of infection (wound or vascular catheter site), but no infections were attributed to a pulmonary or urinary tract site. Eleven patients (69%) were cured, including six who underwent emergent second operations. CONCLUSION: Patients with multiple blood cultures positive for organisms other than gram-negative bacilli are at risk of EO-PVE, even when a primary wound infection or vascular catheter site infection is recognized and treated.

Prosthetic valve endocarditis resulting from nosocomial bacteremia. A prospective, multicenter study.

OBJECTIVE: To determine the incidence of endocarditis in bacteremic patients with prosthetic heart valves and the risk factors for and the effect of duration of antibiotic therapy on development of endocarditis in such patients. DESIGN: Multicenter, prospective observational study. SETTING: Six university teaching hospitals with high-volume cardiothoracic surgery. PARTICIPANTS: One hundred seventy-one consecutive patients with prosthetic heart valves who developed bacteremia during hospitalization. MEASUREMENTS AND MAIN RESULTS: Patients were evaluated when they were identified as having bacteremia and 1, 2, 6, and 12 months after its occurrence. Of 171 patients, 74 (43%) developed endocarditis: Fifty-six (33%) had prosthetic valve endocarditis at the time bacteremia was discovered ("endocarditis at outset"), whereas 18 (11%) developed endocarditis a mean of 45 days after bacteremia was discovered ("new endocarditis"). Mitral valve location and staphylococcal bacteremia (Staphylococcus aureus or S. epidermidis) were significantly associated with the development of "new" endocarditis. All 18 cases of new endocarditis were nosocomial, and in 6 of these cases (33%) bacteremia was acquired via intravascular devices. Twenty-one patients without evidence of endocarditis at the time of bacteremia received short-term antibiotic therapy (< 14 days); 1 patient (5%) developed endocarditis. Eleven of 70 patients (16%) who received long-term antibiotic therapy (> 14 days) developed endocarditis (P > 0.2). CONCLUSIONS: Bacteremic patients with prosthetic heart valves were at notable risk for developing endocarditis, even when they received antibiotic therapy before endocarditis developed and regardless of the duration of such therapy. Intravascular devices were a common portal of entry.

Infection prevention guidelines for cardiac catheterization laboratories. Society for Cardiac Angiography and Interventions Laboratory Performance Standards Committee.

The following guidelines for prevention of catheterization laboratory infections are based on standard precautions for infection prevention in surgical wounds. Specific recommendations for patient preparation include proper methods for hair removal, skin cleaning and draping, antibiotic prophylaxis, wound irrigation and dressing, and sheath removal. Sterile precautions should be more vigorous for cutdown procedures compared to percutaneous. Caps, masks, gowns, and gloves help to protect both the patient and operator. Handwashing is the most important procedure for preventing infections. Maintenance of the catheterization laboratory environment includes appropriate cleaning, limitation of traffic, and maintenance of adequate ventilation. Proper catheterization technique and appropriate use of sterile equipment will decrease the wound infection rate. Protection of personnel may be accomplished by proper gowning and gloving, disposal of contaminated equipment, and care of puncture wounds and lacerations. All personnel should receive vaccination for hepatitis B.

Diagnosis and management of infective endocarditis.

Advances in chemotherapy and surgery have significantly improved the outcome of infective endocarditis, but the disease remains a therapeutic challenge with an overall mortality of 20%. More cases of infective endocarditis seen today are associated with prosthetic heart valves, intravenous drug abuse, or complications of medical and surgical technology. Prosthetic valve endocarditis occurs in 1% to 4% of patients with prosthetic valves. Echocardiography is not a precise diagnostic test for endocarditis, but it helps detect a variety of cardiac lesions, including valvular incompetence, annular ring abscesses, and sometimes vegetations. Serum bactericidal titers are predictive of neither cure nor treatment failure. The principal indication for urgent surgical intervention is acute valvular dysfunction. Other considerations for surgery include evidence of myocardial invasion, infection by antibiotic-resistant organisms, and large vegetations. For patients at risk of infective endocarditis, antibiotic prophylaxis during invasive procedures is an accepted practice.

Decreased infections in cardiac transplant recipients on cyclosporine with reduced corticosteroid use.

Fifty patients undergoing orthotopic cardiac transplantation were monitored over 34 months for evidence of infection. Four separate immunosuppressive protocols were used during the course of the study; the most recent protocol (protocol 4) employed significantly lower overall steroid dosages than the earlier protocols (protocols 1,2, and 3). All immunosuppressive regimens used cyclosporine, and azathioprine was added in the last three protocols. Statistical techniques to compare the occurrence of infection in protocols 1,2, and 3 v protocol 4 showed that patients in protocol group 4 (n = 21) had significantly more time free of pneumonia (P = .02) and major infections (P = .04) and marginally more time free of symptomatic cytomegalovirus infection (P = .08) than patients in protocol groups 1, 2, and 3 (n = 29). The median incidence of major infection per month was lower for protocol group 4 (P = .02). The time free of viral infection did not differ significantly between the two groups (P = .75) nor did the median incidence of rejection per month (P = .19). The authors conclude that reduction of steroid dosages in cardiac transplant patients receiving cyclosporine is associated with a significant decrease in the incidence of clinically important infections.

Outpatient antibiotic therapy for urinary tract infections in women.

Culture may not be required to confirm the diagnosis of urinary tract infections in young women with symptoms; antimicrobial therapy usually resolves symptoms. While relapse may occur more frequently with single-dose therapy, late recurrence rates are the same and side effects are less than with multiple-dose therapy. Patients with relapsing infection or frequent recurrence are candidates for chronic prophylaxis with low-dose antimicrobial or prompt self-administered therapy.