Infective endocarditis: incidence and mortality in the North East Thames Region

A survey of infective endocarditis in the North East Thames Regional Health Authority was carried out over a period of 30 months from 1982 to 1984. The incidence, clinical characteristics, and in-hospital mortality were studied. Important causes of endocarditis were dental treatment, the presence of dental disease, drug abuse, and cytoscopy. The omission or incorrect administration of antibiotic prophylaxis in patients with valve disease was noted, but failure of correctly prescribed antibiotic prophylaxis was not recorded. Adverse prognostic features were increased age, prosthetic valve infection, Gram negative or staphylococcal infections, and aortic valve involvement. In contrast, mortality was lower in patients with mitral valve prolapse, ventricular septal defect, and streptococcus viridans infection. Deaths were usually attributable to irreversible complications present at the time of diagnosis. Vegetations were detected on the echocardiogram in half of those studied and mortality was higher in those with vegetations than without. Operation for native valve infection was associated with a low mortality and it is likely that the overall mortality for infective endocarditis has been improved by surgical intervention.     

Infective endocarditis at autopsy: 1965-1969

Patterns of infective endocarditis as seen at autopsy during a five year interval, 1965 through 1969, were reviewed. The frequency of infective endocarditis was relatively high (forty-seven of 1,881 patients, 2.5 per cent). Failure of clinical recognition of infective endocarditis in 43 per cent of the forty-seven patients is a major factor in the relatively high mortality of this disease. In sixteen of the forty-seven patients (34 per cent) a prosthetic heart valve was present. Seven of these sixteen had active infective endocarditis on a prosthesis which had not been inserted specifically for the treatment of infective endocarditis. All seven patients were receiving usual antibiotic therapy and represent antibiotic treatment failures. In the remaining nine patients, the prosthetic valves had been inserted to correct hemodynamic sequelae secondary to valve deformity following antibiotic therapy of infective endocarditis. In these nine patients, the infection was inactive at the time of autopsy. Valve perforations were present or had been surgically corrected in twenty-two of the forty-seven patients (47 per cent). Intractable congestive heart failure was the cause of death in only 8.5 per cent of our series. Thus in our experience infection has replaced congestive heart failure as the most frequent cause of death.     

Epidemiología de la endocarditis infecciosa en España en los últimos 20 años

Infective endocarditis is an uncommon disease, with an estimated incidence of 3.1 to 3.7 episodes per 100 000 inhabitants/year. The incidence is highest in elderly people. The microorganisms most frequently isolated in infective endocarditis are staphylococci and streptococci. In the last few decades, the spectrum of heart diseases predisposing to infective endocarditis has changed, since degenerative heart disease is the most common valve disease, and there are an increasing number of infective endocarditis patients without previously known valve disease. In addition, up to one-third of infective endocarditis patients become infected through contact with the health system. These patients are more frail, which leads to higher in-hospital mortality. As a result of substantial epidemiological changes, few cases of infective endocarditis can be prevented by antibiotic prophylaxis. Despite advances in medical and surgical treatment, in-hospital mortality among infective endocarditis patients is high. Nevertheless, there is room for improvement in reducing the rate of nosocomial bacteremia, the prompt diagnosis of infective endocarditis in at-risk patients, and the early identification of patients with a highest risk of complications, as well as in the creation of multidisciplinary teams for the management of this disease.     

Profile of right-sided endocarditis: an Indian experience

The clinical profile of right-sided infective endocarditis in India was studied from a review of records of patients with infective endocarditis admitted to this hospital. From November 1982 to November 1989, 109 patients with infective endocarditis showed vegetations on cross-sectional echocardiography confirming the diagnosis of infective endocarditis. In 19 (17.4%) patients, only the right side of the heart was involved: specifically the tricuspid valve alone in 10; tricuspid and pulmonary valves in 4; tricuspid valve and right ventricular outflow tract in 1; tricuspid valve and right ventricular free wall in 1; pulmonary valve alone in 2; and bifurcation of pulmonary trunk in 1. Eleven patients (57.9%) had underlying congenital heart disease whereas the remaining 8 patients (42.1%) did not have any underlying heart disease. The latter group, therefore, had isolated right-sided infective endocarditis. Previous illnesses leading to isolated right-sided infective endocarditis were: puerperal sepsis in 4; septic abortion in 1; staphylococcal pneumonia in 2; and epididymoorchitis in one. Eight out of 11 patients with congenital heart disease did not report any previous illness. In the remaining 3, right-sided endocarditis followed cardiac surgery in one; dental extraction without prophylaxis in one; and pulmonary balloon valvoplasty in one. All patients with isolated right-sided infective endocarditis had features of septicaemia, but a murmur of tricuspid regurgitation was audible in only 4 (50%) of them. We conclude that, unlike western reports, the pattern of right-sided infective endocarditis in India is different. No drug addict with right-sided infective endocarditis was seen; puerperal sepsis and septic abortion were the commonest causes of isolated right-sided infective endocarditis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Infective endocarditis: diagnosis, treatment, and mortality, as related to surgical timing and infectious organism

To evaluate the timing of surgical treatment in infective endocarditis and to determine the relationship between the risk of mortality and the species of infectious organism, we reviewed a consecutive series of 65 cases involving patients with infective endocarditis who had been treated over a 17-year period. The patients included 41 males and 24 females, who ranged in age from 6 to 85 years (mean, 39.3 years). Forty-five had native valve endocarditis, 14 had prosthetic valve endocarditis, and six had endocarditis associated with congenital heart defects. Fifty-two patients underwent valve replacement, which was associated with an overall operative mortality of 19%. Those who underwent valve replacement during the early active stage (first 3 weeks) of infection had a higher mortality rate than those who had surgery either during the late active stage (second 3 weeks) of infection or after 6 weeks of antibiotic therapy. S. aureus and Pseudomonas organisms were responsible for the most deaths. On the basis of this study, we recommend that, when cardiovascular function permits, patients who are hemodynamically stable and free of emboli should receive 4 to 6 weeks of antibiotic therapy before undergoing surgical treatment. In contrast, patients with high-risk organisms are more likely to survive if subjected to early surgical intervention.     

Do dentists enforce correctly the recommendations for prophylaxis of bacterial endocarditis?]

Recommendations for the prophylaxis of infective endocarditis have been published by working groups in several countries. We performed an enquiry amongst 276 dentists in Geneva to evaluate how the Swiss recommendations were applied. Of the 183 dentists who answered, the majority knew that extraction (85%) or scaling (76%) required prophylaxis. They correctly prescribed antibiotics to patients with valve prostheses (84%), to those with rheumatic heart disease (80%), a previous history of endocarditis (73%) or congenital heart disease (49%). Not conforming to the recommendations, many dentists considered that coronary bypass surgery (40%), mitral valve prolapse without mitral regurgitation (30%) or previous myocardial infarction (22%) also required antibiotic prophylaxis. Only 34% of dentists used the recommended 3 g of amoxicillina, the others preferring a lower dose of another antibiotic. About one third started prophylaxis 1 to 3 days too early and less than 20% used the suggested single dose of antibiotics. These results showed that dentists caring for cardiac patients should be better informed of the risks of endocarditis and its prevention. We make a few suggestions to improve antibiotic prophylaxis.     

Infective endocarditis caused by nutritionally variant streptococci

BACKGROUND: Infective endocarditis caused by nutritionally variant streptococci (NVS) has a higher rate of complications than endocarditis caused by other streptococci. The bacteriologic failure rate and the mortality rate are high. However, current knowledge on this disease derives from previous patient data from 1987. Recent case reports showed successful antibiotic treatment in the absence of surgery. Here, we report the clinical outcome of infective endocarditis caused by NVS in our hospital. METHODS: Data were collected by retrospective case note review. RESULTS: Between 1996 and 2006, there were 8 cases of NVS endocarditis: 4 patients had infection caused by Abiotrophia defectiva and 4 patients had infection caused by Granulicatella adiacens. Vegetation size on echocardiography was large (10 mm) in 7 patients, and embolization occurred in 3 patients. Patients were treated with penicillin and gentamicin initially, and 3 of them were successfully treated. The regimens were shifted to vancomycin, teicoplanin, or cefotaxime in 2 cases because of poor therapeutic responses. A total of 4 patients underwent early valve replacement successfully because of severe heart failure. Three patients underwent mitral valve repair successfully at the time of 2, 4, and 7 months after the diagnosis of endocarditis. The valve cultures at surgery were negative. There was no mortality or relapse. The bacteriologic failure rate was zero. CONCLUSIONS: Antibiotic treatment with penicillin and gentamicin had a high rate of success in patients with infective endocarditis caused by NVS. Early surgical intervention should be considered in those patients with deteriorating heart failure due to valve destruction.     

Surgical therapy of infective endocarditis

Therapy of infective endocarditis (IE) remains a particular challenge due to a relative high morbidity and mortality. Cardiac surgery is established as a cornerstone in therapy for native valve endocarditis (NVE) as well as for prosthetic valve endocarditis (PVE) and is required in 30% of patients with active IE. The basic aim of surgery in IE is the radical debridement of infected tissue and reconstruction of valve function either by reconstructive valve surgery or valve replacement. Indication for surgery depends on several clinical variables, the main indication remains heart failure due to severe heart valve defects or prosthetic valve dysfunction. Surgical therapy of NVE can be performed with good clinical results in the early and late follow-up. Surgical therapy of PVE is still associated with quite high mortality up to 80% in some risk groups. This indicates the particular importance of focus evaluation and antibiotic prophylaxis after primary surgery for infective endocarditis.     

Prophylaxis of infective endocarditis: current tendencies, continuing controversies

Infective endocarditis is a severe disease with high mortality, and results most often from the combination of bacteraemia (sometimes provoked) and a predisposing cardiac condition. Prophylaxis for infective endocarditis has been recommended by different countries on the basis of the supposed pathophysiology of the disease, although no randomised clinical trial has confirmed its efficacy. We review the data presented over the past few decades, challenge the principles underlying prophylaxis recommendations, and analyse the arguments that explain the general tendency in very recent years to decrease prophylaxis indications. Such arguments include the probable important role of everyday-life bacteraemia in the occurrence of infective endocarditis, the estimated huge number of prophylaxis doses to be given to avoid a single case of infective endocarditis, and the lack of scientific evidence to identify those procedures that should lead to prophylaxis. Recommendations for prophylaxis are now essentially focused on patients with high-risk predisposing cardiac conditions before dental procedures.     

Epidemiology of bacterial endocarditis in The Netherlands. II. Antecedent procedures and use of prophylaxis.

BACKGROUND--The reported frequency with which endocarditis is ascribed to an antecedent dental or medical procedure varies from 3% to 62%. METHODS--We performed a nationwide prospective study of the epidemiology of bacterial endocarditis in the Netherlands. During a 2-year period, all consecutively hospitalized patients suspected of having endocarditis were visited while still hospitalized for a review of the medical record and an in-person interview that focused on antecedent procedures and administered prophylaxis. All information was checked with pharmacists and dental and medical practitioners. RESULTS--Of 427 patients with late prosthetic or native valve endocarditis, 275 were eligible for antibiotic prophylaxis because of a previously known cardiac lesion (n = 197) or a prosthetic valve (n = 78). Of these 275 patients, 64 (23.3%) had undergone a procedure with an indication for prophylaxis within 180 days of onset; in 31 (11.3%) the procedures had been within 30 days of onset. Antibiotic prophylaxis had been administered to 17 (26.6%) of the 64 patients and to eight (25.8%) of the 31 patients. CONCLUSION--The results indicate that medical and dental procedures cause only a small fraction of endocarditis. The majority of patients develop the disease along other routes. For an incubation period of 180 days, full compliance with prophylaxis might have prevented endocarditis in 47 (17.1%) of 275 patients with late prosthetic or native valve endocarditis involving a previously known cardiac lesion who underwent a procedure with an indication for prophylaxis. For an incubation period of 30 days, prophylaxis might have prevented endocarditis in 23 (8.4%) of these 275 patients, or 5.3% of all patients with endocarditis (n = 427).     

Does prophylaxis prevent postdental infective endocarditis? A controlled evaluation of protective efficacy

PURPOSE: Despite the American Heart Association's (AHA) recommendations for antibiotic prophylaxis to prevent infective endocarditis, no controlled clinical evidence exists for the effectiveness of this intervention. The purpose of this case-control study was to determine whether antibiotic prophylaxis for a dental procedure reduces the risk of infective endocarditis in persons with high-risk cardiac lesions. PATIENTS AND METHODS: Cases consisted of eight subjects with high-risk lesions (six mitral, one aortic, one uncorrected tetralogy) whose first-time, native-valve infective endocarditis occurred within 12 weeks of a dental procedure and was diagnosed between 1980 and 1986. For each case subject, three control subjects were chosen from patients who underwent echocardiographic evaluation between 1980 and 1986, and who were matched for the specific high-risk lesion and age. Use of antibiotic prophylaxis, which was determined by interviews with patients and supplemented by the dentists, was defined as antibiotic taken both before and after the dental procedure. RESULTS: Antibiotic prophylaxis was used by only one of eight (13%) case subjects compared with 15 of 24 (63%) control subjects, for an odds ratio of 0.09, which is clinically impressive (indicating 91% protective efficacy) and statistically significant (p = 0.025). CONCLUSION: Although this report does not specifically assess the value of antibiotic prophylaxis for the current AHA recommendations, the use of antibiotic prophylaxis in persons with high-risk cardiac lesions is supported by the magnitude of protective efficacy observed in this study.     

New French recommendations for the prophylaxis of infectious endocarditis

New French recommendations on infective endocarditis (IE) prevention were recently published and mark a turning point in the history of antibiotic prophylaxis. Endocarditis is an evolving disease, and its clinical and microbiological profile dramatically changes over time. The French surveys that were conducted in 1991 and 1999 showed variations in underlying heart disease with a decrease in native valvular disease and an increase of IE in patients without previously known heart disease. Moreover, the distribution of responsible microorganisms dramatically changed over time, with a marked decrease of oral streptococci. In addition, some dogmas are now challenged. First of all, the part of responsibility of dental procedures is debated, as dental bacteraemia possibly responsible of endocarditis are more likely due to daily manoeuvres such as tooth brushing or chewing gum than to occasional dental procedures. Moreover, as suggested by case-control studies, efficacy--or lack of efficacy--of antibiotic prophylaxis is far from being clinically proved. For all these reasons, the proportion of theoretically avoidable endocarditis seems very low, and the benefit of largely and systematically applied antibiotic prophylaxis may be discussed, not only in terms of financial cost but also in terms of microbiological threat of emergence of antibiotic resistant bacteria. So, the general idea of those new recommendations was to maintain the principle and the modalities of antibiotic prophylaxis, but to limit its indications to situations at high benefit to risk ratio, i.e. procedures at high risk in patients at high risk. Depending on the situation, antibiotic prophylaxis may be either recommended or become optional and decision-making factors are defined. Furthermore, the importance of general prophylaxis was emphasised, concerning more specifically oral and cutaneous hygiene, and patients and practitioners' education, such as, for example, recommendations on blood cultures to be performed before any antibiotic treatment in case on fever occurring in a patient at risk during the 3 months following a procedure at risk.     

Dental health, prophylactic antibiotic measures and infective endocarditis: an analysis of the knowledge of susceptible patients

A questionnaire was administered to 338 cardiac patients susceptible to infective endocarditis seen at the outpatient clinic or a cardiac ward. The questionnaire consisted of a series of questions on the educational, social, familial and professional background, the medical and dental history and the knowledge of the patient on prophylaxis of infective endocarditis. Univariate analysis (chi-square test) and stepwise discriminant analysis were used to evaluate the factors responsible for the presence or absence of an acceptable degree of awareness of infective endocarditis. More than half of the patients had no knowledge on prophylactic measures. The time since the diagnosis of heart disease, an edentulous state, written instructions received in the past on prophylaxis, the location of the follow-up, the level of education and previous prosthetic valve surgery were factors retained by discriminant analysis. A discriminant score was calculated for each patient and permitted classification in subgroups with a high, intermediate and low probability of presence of knowledge. This was simplified by classifying patients according to the number of risk factors. An answer to one of the six variables, selected by discriminant analysis, unfavorable for the presence of knowledge, was considered as a risk factor. Risk factor analysis must be considered as an important tool in the education of patients on the risk and prophylaxis of infective endocarditis.     

Healed left-sided infective endocarditis: A clinicopathologic study of 59 patients

Clinical and morphologic observations are described in 59 patients who had a history of active left-sided infective endocarditis that had been eradicated by antibiotic therapy. Of the 59 patients, 42 were from a group of 584 necropsy patients with fatal cardiac valve disease of various types; the remaining 17 were from a group of 79 patients who had undergone mitral or aortic valve replacement, or both, because of severe mitral or aortic regurgitation, or both. Examination of the heart at necropsy (42 patients) or at valve replacement (17 patients) disclosed that 30 (51 percent) had anatomic lesions that could readily be attributed to the active infective endocarditis that healed: cuspal perforations in 16 patients, rupture of chordae tendineae in 15 and aneurysms at or near the involved valve in 3. Unequivocal residua of the valve infection were more common in the purely incompetent than in the stenotic cardiac valves. Comparison of observations in the 42 necropsy patients with healed left-sided infective endocarditis with observations previously reported in 74 necropsy patients with active left-sided infective endocarditis showed that among the patients with healed endocarditis the infection more commonly involved a previously abnormal valve, the causative organism was more likely to be alpha streptococcus and recognized predisposing factors (opiate addiction, alcoholism, immunodeficiencies, operative procedures) were less frequent.     

Dental extraction and infective endocarditis prophylaxis: current recommendations

PURPOSE: Antibiotic prophylaxis for infective endocarditis is still debated because of unproven efficacy and risk of side effects. French recommendations for infective endocarditis prophylaxis were revised in 2002 and its indications were restricted. CURRENT KNOWLEDGE AND KEY POINTS: Several arguments plead against prophylaxis: the absence of scientific evidence of its efficacy, the very high number of antibiotic doses required to prevent a very small number of endocarditis, the possible failure of prophylaxis even if correctly administered and a lack of compliance with current recommendations. High-risk patients for whom dental extraction is required should receive prophylaxis. For moderate-risk patients, prophylaxis is optional and should be discussed for each case individually. FUTURE PROSPECTS AND PROJECTS: Although prophylaxis is discussed, one should focus on prevention measures, such as dental hygiene and education of physicians, dentists and patients.     

Trend and contributing factors of in-hospital deaths in patients with infective endocarditis over the last twenty years

OBJECTIVES: To evaluate the changes in the clinical background to infective endocarditis and identify the contributing factors to in-hospital deaths over the last 20 years. METHODS: Seventy-five patients (mean age 48.2 +/- 24.0 years) with infective endocarditis treated between January 1984 and December 2003 at our hospital were evaluated retrospectively. The patients were divided into two groups (first decade, n = 26 and second decade, n = 49). RESULTS: The infection route was unknown in 65% of the patients, but the oral route was the most common known route (16.0%). Congenital heart disease (24.0%)was the most common background disease, followed by valvular heart disease (22.7%), and post prosthetic valve replacement (22.7%). The mitral valve was most frequently infected(56.0%), followed by the aortic valve (34.7%). Multi-valve infection was present in 13.3% of the patients. Although the frequency of streptococcal endocarditis reduced, that of staphylococcal endocarditis increased in the second decade. The overall in-hospital mortality was 26.7%, but slightly improved in the second decade (34.6% vs 22.4%, p = 0.26). The overall in-hospital mortality was similar between the surgically treated group and the non-surgically treated group (25.0% vs 27.3%, NS). In the surgically treated group, in-hospital mortality was lower in the second decade than the first decade, but higher in the group treated for active infective endocarditis. Multivariate analysis found age > or = 51 years, renal insufficiency, neurological abnormality, and culture negative as predictors of in-hospital mortality. CONCLUSIONS: Rapid and appropriate primary medical treatment are important in the active phase of infective endocarditis. Age > or = 51 years was the strongest predictor of in-hospital infective endocarditis death.     

感染性心内膜炎主动脉瓣置换手术方法探讨

目的探讨感染性心内膜炎主动脉瓣置换的手术方法。方法回顾分析我院手术治疗的3例感染性心内膜炎主动脉瓣病变患者的临床资料及间断全层缝合主动脉壁置换主动脉瓣的手术方法。术中均可见主动脉瓣赘生物,瓣叶裂,穿孔,主动脉瓣环水肿,主动脉内膜断裂,瓣周脓肿形成。切除病变主动脉瓣,清除坏死组织及赘生物,以碘伏涂抹主动脉根部并浸泡机械瓣膜及换瓣线,游离主动脉根部至瓣环水平,避免损伤冠状动脉,带垫片换瓣线自主动脉壁外进针,垫片置于主动脉壁外侧,16-20针间断缝合,机械瓣环上打结,置换机械瓣膜。结果3例患者术后恢复顺利,3个月至1年随诊,预后良好。结论间断全层缝合主动脉壁置换主动脉瓣方法可以预防复发感染性心内膜炎,减少瓣周漏的发生,安全、有效,远期效果良好。     

Cardiac conduction abnormalities complicating native valve active infective endocarditis

Two hundred eleven episodes of native valve active infective endocarditis treated at the Massachusetts General Hospital between 1975 and 1983 were reviewed. The aortic (36%) and mitral (33%) valves were most frequently involved, but in 21% of the cases the site of infection could not be localized. Streptococcal (50%) and staphylococcal (35%) species were the most frequently isolated pathogens. New or changing (“unstable”) conduction abnormalities developed in 9% of the patients, while an additional 7% had conduction abnormalities of “indeterminate” age. Unstable conduction block was more likely to develop in patients with aortic valve infective endocarditis than in those with mitral infection. Surgery was performed in 23% of the patients. Unstable conduction abnormalities were significantly associated with valve replacement, but in a multivariate analysis, this effect could be explained by the site of valvular infection. The mortality rate was 20%. Patients with unstable conduction abnormalities had a significantly higher mortality rate, even after other significant predictors of death (age, type of causative organism) were taken into account. Patients whose conduction changes persisted had a worse prognosis than those with transient conduction abnormalities. Although more hemodynamically compromised, patients with unstable conduction block who underwent valve replacement did at least as well as those given medical therapy alone. Patients with native valve active infective endocarditis in whom persistent, unstable conduction abnormalities develop without other identifiable cause, especially in the presence of aortic valve infection, should be considered for valve replacement.     

Clinical Characteristics and Evolution of Recurrent Infectious Endocarditis in non Drug Addicts

INTRODUCTION AND OBJECTIVES: Recurrence of infection is observed in a high proportion of patients who have had infective endocarditis in the past. The aim of our study was to evaluate the possible differences between the first and the recurrent episodes of endocarditis, as well as to assess the outcome and prognosis of patients with recurrent endocarditis. PATIENTS AND METHOD: We reviewed a series of 13 episodes of recurrent endocarditis from among 196 cases of infective endocarditis involving non-drug-addict patients in two hospitals from 1987 to 2000. RESULTS: There were no differences between recurrent and first episodes of endocarditis according to age, sex, heart valve involved or causal microorganisms. Prosthetic valve endocarditis was more common in patients with recurrent endocarditis (86% versus 27%; p < 0.001). Although there were no differences in the rate of complications or early surgery, overall mortality was significantly higher in patients with recurrent endocarditis (53% versus 27%: p < 0.05). When early and late mortality were analysed separately, the differences did not achieve significance. CONCLUSIONS: Recurrent endocarditis was frequent in our series (7% of all cases). The features were similar to those of the first episode except for a higher rate of prosthetic valve endocarditis and a higher overall mortality.     

Ten Years of Infective Endocarditis: A Clinicopathologic Study

ABSTRACT The records of 46 patients with infective endocarditis diagnosed either clinically or postmortem were analyzed. Twenty-six patients were over 60 years of age. S. aureus was the predominant organism, almost exclusively found in patients with acute endocarditis. Thirty-six patients had pre-existing heart disease, the most common being non-rheumatic valvular calcification and congenital defects. Two thirds of the patients, especially those with aortic valve regurgitation, developed new or progressive heart failure. A correct clinical diagnosis was established in only 30 patients. Twenty-three patients died, the mortality being 71% in acute and 32% in subacute disease. Only one of eight patients with prosthetic valve infection died. Four patients required urgent valve replacement. Early surgical intervention should be considered in patients with uncontrolled heart failure.