Purpose
To analyze the clinical characteristics of blood culture-negative endocarditis (BCNE) and how it compares to those of blood culture-positive endocarditis (BCPE) cases and show how molecular ...tools helped establish the etiology in BCNE.
Methods
Adult patients with definite infective endocarditis (IE) and having valve surgery were included. Valves were studied by polymerase chain reaction (PCR). Statistical analysis compared BCNE and BCPE.
Results
One hundred and thirty-one patients were included; 53 (40 %) had BCNE. The mean age was 45 ± 16 years; 33 (62 %) were male. BCNE was community-acquired in 41 (79 %). Most patients were referred from other hospitals (38, 73 %). Presentation was subacute in 34 (65 %), with fever in 47/53 (90 %) and a new regurgitant murmur in 34/42 (81 %). Native valves were affected in 74 %, mostly left-sided. All echocardiograms showed major criteria for IE. Antibiotics were used prior to BC collection in 31/42 (74 %). Definite histological diagnosis was established for 35/50 (70 %) valves. PCR showed
oralis
group streptococci in 21 (54 %),
S. aureus
in 3 (7.7 %),
gallolyticus
group streptococci in 2 (5.1 %),
Coxiella burnetii
in 1 (2.5 %) and
Rhizobium
sp. in 1 (2.5 %). In-hospital mortality was 9/53 (17 %). Fever (
p
= 0.06, OR 4.7, CI 0.91–24.38) and embolic complications (
p
= 0.003, OR 3.3, CI 1.55–6.82) were more frequent in BCPE cases, while new acute regurgitation (
p
= 0.05, OR 0.3, CI 0.098–0.996) and heart failure (
p
= 0.02, OR 0.3, CI 0.13–0.79) were less so.
Conclusions
BCNE resulted mostly from prior antibiotics and was associated with severe hemodynamic compromise. Valve histopathology and PCR were useful in confirming the diagnosis and pointing to the etiology of BCNE.
Embolic complications of infective endocarditis are common. The impact of asymptomatic embolism is uncertain.
To determine the frequency of emboli due to IE and to identify events associated with ...embolism.
Retrospective analysis of an endocarditis database, prospectively implemented, with a post hoc study driven by analysis of data on embolic events. Data was obtained from the International Collaboration Endocarditis case report forms and additional information on embolic events and imaging reports were obtained from the medical records. Variables associated with embolism were analyzed by the statistical software R version 3.1.0.
In the study period, 2006–2011, 136 episodes of definite infective endocarditis were included. The most common complication was heart failure (55.1%), followed by embolism (50%). Among the 100 medical records analyzed for emboli in left-sided infective endocarditis, 36 (36%) were found to have had asymptomatic events, 11 (11%) to the central nervous system and 28 (28%) to the spleen. Cardiac surgery was performed in 98/136 (72%). In the multivariate analysis, splenomegaly was the only associated factor for embolism to any site (p<0.01, OR 4.7, 95% CI 2.04–11). Factors associated with embolism to the spleen were positive blood cultures (p=0.05, OR 8.9, 95% CI 1.45–177) and splenomegaly (p<0.01, OR 9.28, 95% CI 3.32–29); those associated to the central nervous system were infective endocarditis of the mitral valve (p<0.05, OR 3.5, 95% CI 1.23–10) and male gender (p<0.05, OR 3.2, 95% CI 1.04–10). Splenectomy and cardiac surgery did not impact on in-hospital mortality.
Asymptomatic embolism to the central nervous system and to the spleen were frequent. Splenomegaly was consistently associated with embolic events.
•Patients with isolated right-sided fungal endocarditis had better survival.•Heart failure/medical treatment only were related to death in Candida endocarditis.•Isolated right-sided endocarditis a ...less harmful illness in Candida endocarditis.
To compare the clinical and epidemiological features, treatments, and outcomes of patients with isolated right-sided and left-sided fungal endocarditis and to determine the risk factors for in-hospital mortality in patients with Candida sp endocarditis.
A retrospective review of all consecutive cases of fungal endocarditis from five hospitals was performed. Clinical features were compared between patients with isolated right-sided and left-sided endocarditis. In the subgroup of fungal endocarditis due to Candida species, binary logistic regression analysis was performed to determine variables related to in-hospital mortality.
Seventy-eight patients with fungal endocarditis were studied. Their median age was 50 years; 55% were male and 19 patients (24%) had isolated right-sided endocarditis. Overall, cardiac surgery was performed in 46 patients (59%), and in-hospital mortality was 54%. Compared to patients with left-side fungal endocarditis, patients with isolated right-sided endocarditis had lower mortality (32% vs. 61%; p=0.025) and were less often submitted to cardiac surgery (37% vs. 66%; p=0.024). The most frequent etiology was Candida spp (85%). In this subgroup, acute heart failure (odds ratio 5.0; p=0.027) and exclusive medical treatment (odds ratio 11.1; p=0.004) were independent predictors of in-hospital death, whereas isolated right-sided endocarditis was related to a lower risk of mortality (odds ratio 0.13; p=0.023).
Patients with isolated right-sided fungal endocarditis have particular clinical and epidemiological features. They were submitted to cardiac surgery less often and had better survival than patients with left-sided fungal endocarditis. Isolated right-sided endocarditis was also a marker of a less harmful illness in the subgroup of Candida sp endocarditis.
A endocardite infecciosa é uma doença sistêmica com alta morbimortalidade que se caracteriza pela presença de vegetações em valvas cardíacas infectadas por microrganismos. As complicações ...neurológicas são comuns e graves na endocardite infecciosa de válvulas esquerdas, das quais as mais frequentes são os acidentes vasculares encefálicos.
Descrever os eventos neurológicos mais prevalentes entre pacientes adultos com diagnóstico de endocardite infecciosa definitiva, bem como os fatores relacionados à embolização para sistema nervoso central e a mortalidade no grupo.
Foi realizada avaliação retrospectiva de 2006 a 2019 a partir de uma coorte prospectiva conduzida por centro de referência para cirurgia cardíaca e composta por pacientes com diagnóstico com EI definitiva pelos critérios modificados de Duke. Análise descritiva e comparativa dentre pacientes com e sem eventos neurológicos foi feita no programa Jamovi 1.6.15.
Dentre os 371 pacientes identificados na coorte entre os anos propostos, 96 (25.87%) sofreram eventos neurológicos centrais, sendo os mais comuns o acidente vascular encefálico isquêmico (62,5%) e os aneurismas micóticos intracranianos (27,1%), seguidos de acidente vascular isquêmico com hemorragia (20,8%) e hemorragia intracraniana (12,5%). A embolia para sistema nervoso central nesta população em nossa coorte esteve associada à transferência de outras unidades hospitalares, a valvopatia reumática, à presença de esplenomegalia, lesões de Janeway, hemorragias subungueais, hemorragias subconjuntivais, acometimento mitral, eventos embólicos não centrais (como embolização para baço) e embolização recorrente. Idade igual ou maior a 60 anos foi identificada como fator protetor para eventos cerebrais, e isso não se relacionou a uso de aspirina ou varfarina. Não houve diferença significativa na mortalidade entre os grupos com e sem eventos neurológicos.
Os eventos neurológicos aumentam a gravidade da endocardite infecciosa e estiveram associados a eventos embólicos para outros sítios assim como acometimento de válvula mitral, como visto na literatura. Idade maior que 60 anos foi fator protetor para eventos embólicos para o SNC.
A Endocardite Infecciosa (EI) é uma doença de elevada morbimortalidade que decorre da infecção do endocárdio caracterizada por febre, sopro e embolização para diversos órgãos. Sua expressão ...patológica mais frequente são as vegetações, de onde se desprendem êmbolos. A literatura mostra que a embolia esplênica ocorre em cerca de 1/3 das EI esquerdas.
Realizar revisão sistemática da literatura sobre aspectos radiológicos e histopatológicos da embolia esplênica na EI. Métodos: As palavras-chave “Endocarditis”, “Spleen”, “Splenic emboli”, “Splenic embolism”, “Embolism”, “Tomography”, “Imaging”, “Pathology”, “Histopathology”, “Positron Emission Tomography”, “Computed Tomography” e equivalentes em português foram utilizadas no Embase, PubMed, Bireme e Scielo, no período de 01 janeiro de 2000 a 09 de março de 2021, de publicações em inglês ou português, em adultos. Critérios de exclusão: revisões não sistemáticas, relatos de caso e publicações com foco em embolias não esplênicas.
As estratégias de busca identificaram 1.973 artigos; 1.849 foram excluídos por não elegibilidade verificada pela leitura do título e 71 pela leitura dos resumos. Após a leitura integral, 32 foram excluídos, totalizando 21 artigos elegíveis. As EIs esquerdas nos estudos variaram de 6 a 3.116 casos, a proporção de próteses variou de 24 a 31%, a idade dos pacientes de 43 a 70 anos, e homens foram os mais acometidos (mediana de 60% na proporção). Os exames para detecção de embolias foram: ultrassonografia, tomografia computadorizada (TC), ressonância magnética, PET/CT, SPECT/CT e Ultrassonografia com contraste por microbolhas. O número de embolias esplênicas variou de 1,4% a 71,7%. A TC foi a modalidade de imagem mais utilizada e encontrou em média 25% de frequência de embolia esplênica. Gram positivos foram a etiologia mais frequente. A indicação de cirurgia cardíaca variou de 40 a 100%, enquanto a mortalidade hospitalar de 4,2 a 31,6%. Apenas 2 artigos avaliaram aspectos patológicos da embolia esplênica, ambos em autópsias, e apenas 1 descrevia a histopatologia do baço; neste 27/68 baços (39,7%) estavam comprometidos, sendo 22/27 (81,5%) por infarto e 5/27(18.5%) por abscesso em que infartos predominaram.
A literatura mostra elevada frequência de eventos embólicos esplênicos em estudos tomográficos, embora o rastreio sistemático dos mesmos seja discutido. Estudos patológicos sobre o baço na EI são raros.
Background: Non-HACEK Gram-negative bacilli (NGNB) infective endocarditis (IE) has a growing frequency. We aimed to describe cases of NGNB IE and find associated risk factors. Methods: We conducted a ...prospective observational study of consecutive patients with definitive IE according to the modified Duke criteria in four institutions in Brazil. Results: Of 1154 adult patients enrolled, 38 (3.29%) had IE due to NGNB. Median age was 57 years, males predominated, accounting for 25/38 (65.8%). Most common etiologies were 'Pseudomonas aeruginosa' and 'Klebsiella' spp. (8 episodes, 21% each). Worsening heart failure occurred in 18/38 (47.4%). Higher prevalence of embolic events was found (55,3%), mostly to the central nervous system 7/38 (18.4%). Vegetations were most commonly on aortic valves 17/38 (44.7%). Recent healthcare exposure was found in 52.6% and a central venous catheter (CVC) in 13/38 (34.2%). Overall mortality was 19/38 (50%). Indwelling CVC (OR 5.93; 95% CI, 1.29 to 27.3; p = 0.017), hemodialysis (OR 16.2; 95% CI, 1.78 to 147; 'p' = 0.008) and chronic kidney disease (OR 4.8; 95% IC, 1.2 to 19.1, 'p' = 0.049) were identified as risk factors for mortality. Conclusions: The rate of IE due to NGNB was similar to that in previous studies. 'Enterobacterales' and 'P. aeruginosa' were the most common etiologies. NGNB IE was associated with central venous catheters, prosthetic valves, intracardiac devices and hemodialysis and had a high mortality rate.
Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined.
The International Collaboration on ...Endocarditis-PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non-cardiac device-related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE.
Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management.
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