Search Results (35)

Background/Objectives: Microhematuria is common in patients with infective endocarditis (IE). The present study aims to assess whether the addition of microhematuria in the 2023 Duke-International Society for Cardiovascular Infectious Diseases (ISCVID) minor immunological criteria could enhance its diagnostic performance. Methods: This retrospective study was conducted at the Lausanne University Hospital, Switzerland (2014–2024). All patients with suspected IE and urinalysis within 24 h from presentation were included. The Endocarditis Team classified episodes as IE or non-IE. Microhematuria was defined as >5 red blood cells per high power field (HPF). Results: Among 801 episodes with suspected IE, 263 (33%) were diagnosed with IE. Microhematuria (>5/HPF) was present in 462 (58%) episodes, with no difference between episodes with and without confirmed IE (61% versus 56%; p = 0.223). Based on the 2023 ISCVID-Duke, minor immunological criteria were present in 42 episodes (5%). By adding microhematuria, 473 (59%) episodes met the minor immunological criteria. Sensitivity of the clinical criteria of the 2023 ISCVID-Duke version without and with hematuria was calculated at 75% (69–80%) and 86% (81–90%), respectively. Specificity was at 52% (48–57%) and 40% (36–45%), respectively. Among episodes with suspected IE, microhematuria was associated with female sex, enterococcal bacteremia, sepsis or septic shock, acute kidney injury, non-cerebral embolic events, and bone and joint infection. Conclusions: Microhematuria was frequent among patients with suspected IE, but it was not associated with the diagnosis of IE. The addition of microhematuria in the 2023 ISCVID-Duke minor immunological criteria did not enhance the overall performance of the criteria. Full article

Infective endocarditis (IE) as a diagnosis remains challenging, particularly in prosthetic valve endocarditis (PVE). This study evaluates the diagnostic utility of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in patients with suspected IE. Seventy patients with suspected IE underwent clinical, microbiological, echocardiographic, and ¹⁸F-FDG PET/CT evaluation. Diagnostic performance of PET/CT was assessed against clinical classification based on modified Duke criteria. Definitive PVE was diagnosed in 18 patients (26%), while 52 (74%) had possible IE. PET/CT reclassified 13 patients from possible to definite IE, demonstrating an overall sensitivity of 83.3%, specificity of 93.7%, positive predictive value (PPV) of 83.3%, and negative predictive value (NPV) of 93.7%. Excluding native valve endocarditis cases, sensitivity and specificity increased to 94.1% and 95.7%, respectively. PET/CT detected septic emboli in five patients and incidental malignancies in three cases, underscoring its role in comprehensive patient evaluation. False-negative results were mostly observed in early post-surgical PVE and native valve endocarditis. PET/CT also identified alternative diagnoses in patients reclassified as rejected IE. ¹⁸F-FDG PET/CT provides high diagnostic accuracy for suspected PVE, significantly aiding reclassification of ambiguous cases and detection of extracardiac complications and malignancies. Its integration into diagnostic algorithms may improve clinical management and outcomes in complex IE cases. Full article

Background and Objectives: Infective endocarditis (IE) is a severe, life-threatening infection of the endocardial surface. Its incidence has shifted towards older, immunocompromised patients and those with cardiac devices. Materials and Methods: This study was conducted at the “Sf. Parascheva” Clinical Hospital of Infectious Diseases in Iasi, Romania, and retrospectively analyzed cases of IE from January 1, 2019, to September 30, 2024. It received ethical approval (Approval No. 7/17 June 2024). Results: The study included 130 patients with infectious endocarditis, predominantly men (75.38%), with a median age of 55 years. The most affected age groups were 50–59 and over 60 years, each representing 30.76% of cases. The most frequently implicated etiological agent was Staphylococcus aureus in 33% of cases. The most common antibiotic regimen combined glycopeptides and fluoroquinolones/polymyxins (27% cases). Conclusions: A multidisciplinary approach involving infectious disease specialists, cardiologists, and cardiovascular surgeons is essential for effective treatment. Immediate combined antibiotic therapy is vital for presumed IE cases. Despite advances in diagnosis and treatment, the high mortality rates highlight the importance of timely intervention. Future research should focus on improving preventive and therapeutic strategies for IE. Full article

Background: The 2023 European Society of Cardiology (ESC) guidelines for the management of infective endocarditis (IE) highlighted the essential role of multimodal imaging in the diagnostic algorithm of IE and its complications. Methods: We hereby report a case series of IE in which the diagnosis was confirmed or excluded by the use of multimodal imaging during the period between January 2024 and July 2024 at the Infectious Diseases Clinic, Perugia Hospital, Italy. Results: Six patients were retrospectively included. Prosthetic valve endocarditis (PVE) was suspected in four patients and native valve endocarditis (NVE) in two cases. In patients with prosthetic valves, 18F FDG-PET/CT was performed, except in one case (P1) where cardiac CTA was performed for suspicion of perigraft aneurysm. Patients underwent transesophageal echocardiography (TOE), which was diagnostic in two cases and inconclusive in the remaining cases. In case of inconclusive TOE, the use of multimodal imaging added a major criterion and allowed us to consider (from ‘rejected’ to ‘possible’) or confirm (from ‘possible’ to ‘definite’) the diagnosis of EI based on the 2023 Duke–ESC Criteria. In one case (P6), it was possible to exclude the diagnosis. For patients with diagnostic TOE, 18F FDG-PET/CT allowed for the enhancement of diagnostic accuracy, identifying the site of valve involvement and the extension of the infection to the device (cases P3 and P5, respectively). Conclusions: In clinical practice, the use of cardiac CTA and/or 18F FDG-PET/CT based on the latest ESC guidelines demonstrated a significant impact on the diagnosis and therapeutic management of IE. Full article

Prosthetic valve endocarditis (PVE) has undergone significant changes over the past five decades and is currently affecting an aging population, with an increasing prevalence in patients with transcatheter valve implants. The introduction of transcatheter aortic valve replacement (TAVR) represents a significant advance in the field of interventional cardiology and cardiac surgery. The incidence of IE after TAVR has remained stable, with rates similar to those reported after surgical aortic valve replacement. This is despite significant refinements in the TAVR procedure, with less invasive handling and its extension to younger and healthier patients. TAVR should be considered as a potential treatment option for patients with PVE, despite some differences. In terms of evolutionary advances, there have been notable and significant developments in the fields of microbiology and imaging diagnostics. The 2023 Duke-International Society for Cardiovascular Infectious Diseases diagnostic criteria for infective endocarditis now incorporate significant advances in molecular biology and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography. This has led to a significant enhancement in diagnostic sensitivity for PVE while maintaining the same level of specificity in validation studies. PVE is a deadly disease. A multidisciplinary endocarditis treatment team in a cardiac center is essential to improve outcomes. The availability of novel surgical options allows clinicians to offer an increasing number of patients the opportunity to avoid surgical intervention. Some patients will complete antimicrobial treatment at home. Those with prosthetic valves are eligible for antibiotic prophylaxis before dental procedures. Post-TAVR infective endocarditis (IE) is a subcategory of prosthetic valve endocarditis. This condition presents a particularly complex scenario, characterized by a distinctive clinical and microbiological profile, a high prevalence of IE-related complications, an ambiguous role of cardiac surgery, and a poor prognosis for the majority of patients with TAVR IE. The number of TAVR procedures is set to skyrocket in the coming years, which will undoubtedly lead to a significant rise in the number of people at risk of this life-threatening complication. This review will provide an overview of this rare complication in light of the advent of IE following TAVR. It is crucial to gain a comprehensive understanding of the disease and its associated complications to enhance clinical outcomes. Full article

Prosthetic valve endocarditis (PVE) is the medical term used to describe a focus of infection involving a valvular substitute within the heart. It is a significant concern in the field of cardiology, and the epidemiology of PVE has seen notable developments over the last five decades. The disease currently affects an older demographic and is becoming increasingly prevalent in patients with transcatheter-implanted valves. It is imperative that we urgently address the significant challenges posed by PVE. It is a disease that has a wide range of potential aetiologies, clinical presentations, and courses. In developed countries, Staphylococcus aureus is now the predominant causative organism, resulting in an aggressive form of disease that frequently afflicts vulnerable or elderly populations. However, it is clear that Enterococcus species present a significant challenge in the context of PVE following TAVR procedures, given their elevated prevalence. The 2023 Duke/International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria now include significant developments in microbiological and image-based techniques for diagnostic purposes, specifically the incorporation of fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography. These developments unequivocally enhance the diagnostic sensitivity for PVE, while maintaining the specificity. They do so in accordance with the results of studies conducted specifically for the purpose of validation. The lack of rigorous scientific studies and a shortage of funding and resources for research have led to a significant gap in our understanding. Randomized controlled trials could provide invaluable insight and guidance for clinical practice, but they are missing, which represents a major gap. It is clear that there is an urgent need for more research. PVE is a life-threatening condition that must be handled by a multidisciplinary endocarditis team at a cardiac centre in order to improve outcomes. The emergence of innovative surgical techniques has empowered clinicians to steer more patients away from surgical procedures, despite the presence of clear indications for them. A select group of patients can now complete parenteral or oral antimicrobial treatment at home. Additionally, antibiotic prophylaxis is the best option for individuals with prosthetic valves who are going to have invasive dental procedures. These individuals should be given antibiotics beforehand. Full article

Infective endocarditis (IE) is a life-threatening condition with increasing global incidence, primarily caused by Staphylococcus aureus, especially methicillin-resistant strains (MRSA). Biofilm formation by S. aureus is a critical factor in pathogenesis, contributing to antimicrobial resistance and complicating the treatment of infections involving prosthetic valves and cardiovascular devices. Biofilms provide a protective matrix for MRSA, shielding it from antibiotics and host immune defenses, leading to persistent infections and increased complications, particularly in cases involving prosthetic materials. Clinical manifestations range from acute to chronic presentations, with complications such as heart failure, embolic events, and neurological deficits. Diagnosis relies on the Modified Duke Criteria, which have been updated to incorporate modern cardiovascular interventions and advanced imaging techniques, such as PET/CT (positron emission tomography, computed tomography), to improve the detection of biofilm-associated infections. Management of MRSA-associated IE requires prolonged antimicrobial therapy, often with vancomycin or daptomycin, needing a combination of antimicrobials in the setting of prosthetic materials and frequently necessitates surgical intervention to remove infected prosthetic material or repair damaged heart valves. Anticoagulation remains controversial, with novel therapies like dabigatran showing potential benefits in reducing thrombus formation. Despite progress in treatment, biofilm-associated resistance poses ongoing challenges. Emerging therapeutic strategies, including combination antimicrobial regimens, bacteriophage therapy, antimicrobial peptides (AMPs), quorum sensing inhibitors (QSIs), hyperbaric oxygen therapy, and nanoparticle-based drug delivery systems, offer promising approaches to overcoming biofilm-related resistance and improving patient outcomes. This review provides an overview of the pathogenesis, current management guidelines, and future directions for treating biofilm-related MRSA IE. Full article

Background: Infective endocarditis is a life-threatening disease with diverse clinical presentations, making diagnosis challenging and requiring a range of complementary tests. The level of suspicion, based on clinical judgment, guides decisions regarding the initiation of empirical treatment and the selection of appropriate diagnostic tools. This study aimed to develop and validate the EndoPredict-Dx score for early prediction of infective endocarditis diagnosis. Methods: Patients admitted to a specialized cardiovascular hospital emergency department with suspected infective endocarditis between January 2011 and January 2020 were included. The primary outcome was left-sided infective endocarditis according to the Duke criteria. Logistic regression was used to derive the scoring system, with internal validation performed through bootstrapping. Candidate variables were obtained from the admission medical history, physical examination, and laboratory parameters. Results: Of the 805 individuals with suspected infective endocarditis (median age 56 years (40–73); 58.6% men), 530 confirmed the diagnosis based on the Duke criteria. The EndoPredict-Dx assigned points for male sex, previous endocarditis, petechiae, heart murmur, suspected embolism, symptoms lasting 14 or more days at the time of admission, hemoglobin level ≤ 12 g/dL, leukocyte level ≥ 10 × 10⁹/L, C-reactive protein level ≥ 20 mg/L, and urine red blood cells ≥ 20,000 cells/mL. Patients were divided into three risk groups. The AUROC was 0.78 (95% CI 0.75–0.81) for the derivation cohort and 0.77 for the internal validation. Conclusions: The EndoPredict-Dx score accurately predicted the likelihood of infective endocarditis using clinical and laboratory data collected at admission. Full article

Background: 18F-fluorodeoxyglucose positron emission tomography–CT (FDG-PET/CT) is useful for identifying infective endocarditis (IE) but also the detection of other concomitant septic foci. Previously, we found that FDG-PET/CT identified an osteoarthritic septic graft (OASG) in 19.1% of IE patients, frequently asymptomatic. These preliminary results encouraged us to extend our analyses to a larger population, including all patients initially explored for suspected IE, to assess the prevalence, characteristics, and OASG locations brought out by FDG-PET/CT and to identify predictive factors. Methods: From a single-center cohort of patients referred for a clinical and/or biological suspicion of IE, we included all patients who underwent FDG-PET/CT, mainly performed to confirm a prosthesis heart valve or a foreign cardiac device infection. We excluded those who did not meet the 2015 modified Duke Criteria and those for whom another infectious diagnosis was finally retained or for whom all bacterial samples were negative. Demographic, clinical, bacteriological, imaging, and therapeutic data were collected. FDG-PET/CT images were retrospectively analyzed by three blinded nuclear medicine specialists to identify OASGs. Results: We identified 72 distinct OASG locations by FDG-PET/CT in 48 of 174 patients (27.6%), mainly located in the spine (21 OASGs in 20 patients); 14 patients (8.0%) had several OASG locations. In total, 43.8% of OASG locations were asymptomatic. In multivariate analysis, the presence of OASGs was associated with musculoskeletal pain (p < 0.001) and tricuspid valve involvement (p = 0.002). Conclusions: FDG-PET/CT is useful for identifying OASGs in patients with suspected IE, especially those with tricuspid IE or musculoskeletal pain. The identification of OASGs could impact antibiotic therapy and would allow adapted orthopedic management to be proposed. Full article

Background/Objectives: Recently, an update of the Duke criteria for the diagnosis of infectious endocarditis has been published: the 2023 Duke-ISCVID criteria. To gain an insight into which proportion of patients are affected by the new criteria, and which criteria might be the most relevant for the expected increase in sensitivity, we analysed data from a registry of cardiovascular infections. Methods: The 2023 Duke-ISCVID criteria were applied to patients who were diagnosed with and treated for endocarditis after having been classified as “possible” endocarditis according to the 2015 ESC Modified Duke criteria. In patients thus newly classified as “definite endocarditis”, diagnostic factors leading to this reclassification were described. Results: Of 397 patients, 48 (12%) did not fulfil the definition “definite infectious endocarditis” according to the 2015 ESC Modified Duke criteria. Of these, six (13%) fulfilled the definition when the 2023 Duke-ISCVID criteria were applied. A main factor triggering this reclassification was the consideration of microorganisms identified using valve PCR. Conclusions: As expected, the sensitivity of the new 2023 Duke-ISCVID criteria is increased in this cohort, mainly through the incorporation of new diagnostic methods in the criteria. Further studies are required to assess the effect on specificity in detail. Full article

Endocarditis, a serious infectious disease, remains a diagnostic challenge in contemporary clinical practice. The advent of advanced imaging modalities has contributed significantly to the improved understanding and management of this complex disease. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) imaging has shown remarkable potential in improving the diagnostic accuracy of endocarditis. In the update of the Modified Duke Criteria, in 2023, The International Society for Cardiovascular Infectious Diseases (ISCVID) Working Group recognized specific 18F-FDG PET/CT findings as a major diagnostic criterion, particularly in patient with prosthetic valve endocarditis. The ability of PET to visualize metabolic activity allows for the identification of infective foci and could differentiate between infective and non-infective processes. This review examines the clinical utility of PET in differentiating infective endocarditis from other cardiovascular pathologies, highlighting its sensitivity and specificity in detecting native and prosthetic valve infections, including patients with transcatheter aortic valve implantation (TAVI), cardiac implantable devices (CIEDs), and left ventricular assistance devices (LVAD). Also, practical aspects and indications are illustrated to optimize the quality of imaging and reduce potential false positive results. In conclusion, the current use of PET in endocarditis has become a valuable diagnostic tool; as technological advances continue, PET will play an increasingly important role in the multidisciplinary approach to the management of endocarditis. Full article

Background/Objectives: Infective prosthesis endocarditis (IE) following transcatheter aortic valve implantation (TAVI) presents significant management challenges, marked by high mortality rates. This study reviews our center’s experience with surgical interventions for IE in patients post-TAVI, focusing on outcomes, challenges, and procedural complexities, and providing an overview of the limited literature surrounding this subject. Methods: This study was executed as a comprehensive retrospective analysis, targeting the clinical outcomes of surgical treatment in patients presenting with PVE following TAVI procedures at our institution. From July 2017 to July 2022, we identified five patients who had previously undergone transfemoral transcatheter aortic valve implantation and were later diagnosed with PVE needing surgery, strictly adhering to the modified Duke criteria. Results: All surgical procedures were reported successful with no intra- or postoperative mortality. Patients were predominantly male (80%), with an average age of 76 ± 8.6 years, presenting mostly with dyspnea (NYHA Class II). The mean follow-up was between 121 and 1973 days, with outcomes showing no occurrences of stroke, myocardial infarction, or major bleeding. One patient expired from unrelated causes 3.7 years post-surgery. The operative and postoperative protocols demonstrated effective disease management with enhanced survival and minimal complications. Conclusions: The surgical treatment of IE following TAVI, though challenging, can be successfully achieved with careful patient selection and a multidisciplinary approach. The favorable outcomes suggest that surgical intervention remains a viable option for managing this high-risk patient group. Our study also highlights the scarce literature available on this topic, suggesting an urgent need for more comprehensive research to enhance understanding and improve treatment strategies. Future studies with larger cohorts are needed to further validate these findings and refine surgical strategies for this growing patient population. Full article

Background: Infective endocarditis (IE) is a pathological condition caused by various microbial agents that can lead to severe complications affecting the heart. Accurate diagnosis is crucial for the effective management of patients with IE. Blood culture is the gold standard for identifying the primary infectious agents, which is a key factor in diagnosing IE using the modified Duke criteria. Objective: The main objective of this study was to investigate the distribution of the etiological agents of IE and the most common secondary diagnoses associated with it. Method: A total of 152 patients aged 23–95 years with a diagnosis of IE and proven etiology (through blood cultures or serological tests) were included in this study. Results: The most common etiological agent identified through blood tests was Enterococcus faecalis, which was detected in 39 patients (23.5%). Staphylococcus aureus was the second most common agent and was identified in 33 patients (19.9%), followed by Staphylococcus epidermidis, which was identified in 12 patients (13.1%). Nine patients (5.8%) had high levels of anti-Coxiella burnetti IgG phase I and II antibodies. Conclusions: IE is a leading cause of death in the Department of Infectious Diseases. Early and accurate diagnosis, along with interdisciplinary treatment, can significantly increase the chances of patient survival. Currently, Enterococcus faecalis and Staphylococcus aureus are the dominant etiological agents of IE, highlighting the need to revise protocols for prophylaxis, diagnosis, and initial treatment of this condition. Full article

Background: As infective endocarditis has particular characteristics compared to other infectious diseases, it is not clear if sepsis scores are reported with good accuracy in these patients. The aim of this study is to evaluate the accuracy of the qSOFA and SOFA scores to predict mortality in patients with infective endocarditis. Methods: Between January 2010 and June 2019, 867 patients with suspected left-sided endocarditis were evaluated; 517 were included with left-sided infective endocarditis defined as “possible” or “definite” endocarditis, according to the Modified Duke Criteria. ROC curves were constructed to assess the accuracy of qSOFA and SOFA sepsis scores for the prediction of in-hospital mortality. Results: The median age was 57 years, 65% were male, 435 (84%) had pre-existing heart valve disease, and the overall mortality was 28%. The most frequent etiologies were Streptococcus spp. (36%), Enterococcus spp. (10%), and Staphylococcus aureus (9%). The sepsis scores from the ROC curves used to predict in-hospital mortality were qSOFA 0.601 (CI95% 0.522–0.681) and SOFA score 0.679 (CI95% 0.602–0.756). A sub-group analysis in patients with and without pre-existing valve disease for SOFA ≥ 2 showed ROC curves of 0.627 (CI95% 0.563–0.690) and 0.775 (CI95% 0.594–0.956), respectively. Conclusions: qSOFA and SOFA scores were associated with increased in-hospital mortality in patients with infective endocarditis. However, as accuracy was relatively lower compared to other sites of bacterial infections, we believe that this score may have lower accuracy when predicting the prognosis of patients with IE, because, in this disease, the patient’s death may be more frequently linked to valvular and cardiac dysfunction, as well as embolic events, and less frequently directly associated with sepsis. Full article

Background: Despite advances in diagnosis and treatment, the incidence and mortality of infective endocarditis (IE) have increased in recent decades. Studies on the risk factors for mortality in endocarditis in Latin America are scarce. Methods: This retrospective cohort study included 240 patients diagnosed with IE according to the modified Duke criteria who were admitted to two university hospitals in Rio de Janeiro, Brazil from January 2009 to June 2021. Poisson regression analysis was performed for trend tests. The multivariate Cox proportional hazards model was used to estimate the hazard ratio (HR) of predictors of in-hospital mortality. Findings: The median age was 55 years (IQR: 39–66 years), 57% were male, and 41% had a Charlson comorbidity index (CCI) score > 3. Healthcare-associated infective endocarditis (54%), left-sided native valve IE (77.5%), and staphylococcal IE (26%) predominated. Overall, in-hospital mortality was 45.8%, and mortality was significantly higher in the following patients: aged ≥ 60 years (53%), CCI score ≥ 3 (60%), healthcare-associated infective endocarditis (HAIE) (53%), left-sided IE (51%), and enterococcal IE (67%). Poisson regression analysis showed no trend in in-hospital mortality per year. The adjusted multivariate model determined that age ≥ 60 years was an independent risk factor for in-hospital mortality (HR = 1.9; 95% CI 1.2–3.1; p = 0.008). Interpretation: In this 12-year retrospective cohort, there was no evidence of an improvement in survival in patients with IE. Since older age is a risk factor for mortality, consensus is needed for the management of IE in this group of patients. Full article