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Aims To determine the prognosis of patients treated for infective endocarditis (IE) according to their healthcare pathway. To assess how the ESC guidelines are implemented concerning the performance of transoesophageal echocardiography, the use of antibiotic therapy, and the performance of valve surgery; and to compare the epidemiological profile of IE according to the type of centres in which the patients are hospitalized. Methods and results In a prospective multicentric study including 22 hospitals in the South-East of France, 342 patients were classified into three groups according to their healthcare pathway: 119 patients diagnosed and taken care entirely in a reference centre or hospital with cardiac surgery [Referral Center (RC) group], 111 patients diagnosed and initially taken care in a non-RC (NRC), then referred in a centre including cardiac surgery [transferred to the Referral Center (TRC) group] and 112 patients totally taken care in the NRC (NRC group). One-year mortality was 26% (88 deaths) and was not significantly different between Groups 1 and 2 (20 vs. 21%, P = 0.83). Patients in the NRC group had a higher mortality (37%) compared with patients in the RC and TRC groups (P Conclusion Prognosis of patients with IE is influenced by their healthcare pathway. Patients treated exclusively in NRC have a worse prognosis than patients treated in referral or surgical centres.

In native mitral valve infective endocarditis (NMIE), the respective values of mitral valve repair (MVRep) and replacement (MVR) are still debated.To compare MVRep and MVR in a large prospective matched cohort.Between 2010 and 2017, all consecutive patients operated on for NMIE in our centre were included prospectively. Clinical and outcome features were compared between the two groups. Primary endpoint was event-free survival, including death, reoperation and relapse. Univariate and multivariable survival analyses and a propensity score analysis were performed.Among 152 patients, 115 (75.7%) underwent MVRep, and 37 (24.3%) MVR. Median follow-up was 28±22months. Surgery was performed during the active phase in 75.0% of patients (25.7% on an urgent basis). Compared with the MVRep group, patients in the MVR group were more frequently intravenous drug abusers (10.8% vs. 0.9%; P=0.016), had a more frequent history of rheumatic fever (13.5% vs. 0%; P=0.001), more aortic abscesses (16.7% vs. 3.5%; P=0.018), larger vegetations (16.6±8.1mm vs. 12.6±9.9mm; P=0.042) and poorer New York Heart Association status (P=0.006). Overall mortality was lower in the MVRep group than in MVR group (11.3% vs. 29.3%; P=0.018). Event-free survival was better in the MVRep group than in the MVR group in univariate analysis (hazard ratio: 2.72, 95% confidence interval: 1.34-5.52; P=0.004). Survival analysis in the propensity-matched cohort showed that MVRep was safer than MVR (log rank test: P=0.018). Multivariable analysis using the Cox proportional hazard model confirmed this finding (hazard ratio: 3.48, 95% confidence interval: 1.15-10.61; P=0.03).MVRep is feasible in most cases of NMIE and, when technically possible, should be preferred, even in urgent surgery.

International audience; Background - Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD). Objectives - This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients. Methods - Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression. Results - A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non-HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p

We systematically survey respiratory and gastrointestinal infections of viral origin in samples sent to our university hospital institute in Marseille, southern France. Here, we evaluated whether the measures implemented to fight COVID-19 had an effect on the dynamics of viral respiratory or gastrointestinal infections.We analysed PCR performed and positive for the diagnoses of viral respiratory and gastrointestinal infections over five years (January 2017-February 2021). Data were collected from our epidemiological surveillance system (MIDaS). Dates and contents of French measures against SARS-CoV-2 were collected from: https://www.gouvernement.fr/info-coronavirus/les-actions-du-gouvernement.Over the 2017-2021 period, 990,364 analyses were carried out for respiratory infections not including SARS-CoV-2, 510,671 for SARS-CoV-2 and 27,719 for gastrointestinal infections. During winter 2020-2021, when the most restrictive lockdown measures were in place in France, a marked decrease of infections with influenza viruses (one case versus 1,839-1,850 cases during 2017-2020 cold seasons) and with the RSV (56 cases versus 988-1,196 cases during 2017-2020 cold seasons) was observed, demonstrating the relative effectiveness of these measures on their occurrence. SARS-CoV-2 incidence seemed far less affected. Rhinoviruses, parainfluenza 3 virus, and the coronavirus NL63 remained at comparable levels. Also, the norovirus winter season positivity rates decreased continuously and significantly over time from 9.3% in 2017-2018 to 2.0% in 2020-2021.The measures taken to control COVID-19 were effective against lower respiratory tract infections viruses and gastroenteritis agents, but not on the agents of the common winter cold and SARS-CoV-2. This suggests that more specific measures to prevent COVID-19 and upper respiratory tract infections need to be discovered to limit the spread of this epidemic.

Summary Background Infective endocarditis (IE) is associated with a high mortality rate, related in part to neurological complications. Studies suggest that valvular surgery should be performed early when indicated, but is often delayed by the presence of neurological complications. Aim To assess the effect of delaying surgery in patients with IE and neurological complications and to identify factors predictive of death. Methods In a prospective, single-centre study in a referral centre for IE, all patients with IE underwent systematic screening for neurological complications. The primary outcome was 6-month death. In patients presenting with neurological complications, the prognosis according to surgical status was analysed and a Cox regression model used to identify variables predictive of death. Results Between April 2014 and January 2018, 351 patients with a definite diagnosis of left-sided IE were included. Ninety-four patients (26.8%) presented with at least one neurological complication. Fifty-nine patients (17.7%) died during 6-month follow-up. Six-month mortality rates did not differ significantly between patients with and without neurological complications (P = 0.60). Forty patients had a temporary surgical contraindication because of neurological complications. During the period of surgical contraindication, seven of these patients (17.5%) died, six (15.0%) presented a new embolic event, and 12 (30.0%) presented cardiac or septic deterioration. In multivariable analysis, predictive factors of death in patients presenting with neurological complications were temporary surgical contraindication (hazard ratio 7.36, 95% confidence interval 1.61–33.67; P = 0.010) and presence of a mechanical prosthetic valve (hazard ratio 16.40, 95% confidence interval 2.22–121.17; P = 0.006). Conclusions Patients with a temporary surgical contraindication due to neurological complications had a higher risk of death and frequent major complications while waiting for surgery. When indicated, the decision to postpone surgery in the early phase should be weighed against the risk of infectious or cardiac deterioration.

International audience; Background: 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG PET/CT) has recently been added as a major criterion in the European Society of Cardiology (ESC) 2015 infective endocarditis guidelines. PET/CT is currently used in patients with suspected prosthetic valve and cardiac device-related endocarditis. However, the value of the ESC classification and the clinical impact of PET findings are unknown in patients with native valve endocarditis (NVE).Aims: Our aims were: to assess the value of the ESC criteria (including PET/CT) in NVE; to determine the usefulness of PET/CT concerning embolic detection; and to describe a new PET/CT feature (diffuse splenic uptake).Methods: Between 2012 and 2017, 75 patients with suspected NVE were included prospectively, after exclusion of patients with uninterpretable or unfeasible PET/CT. Using gold standard expert consensus, 63 cases of infective endocarditis were confirmed and 12 were rejected.Results: Significant valvular uptake was observed in 11 of 63 patients with definite NVE and in no patients who had the diagnosis of infective endocarditis rejected (sensitivity 17.5%, specificity 100%). Among the 63 patients with NVE, a peripheral embolism or mycotic aneurysm was observed in 20 (31.7%) cases. Application of the ESC criteria increased Duke criteria sensitivity from 63.5% to 69.8% (P

Background and objectives 18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines. We and others have demonstrated that18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) / computed tomography (CT) was useful in patients with suspected prosthetic valve and cardiac device IE. However, the sensitivity and specificity of ESC classification is unknown in patients with native valve endocarditis (NVE) as well as the clinical impact of PET findings. Purposes 1. Primary objective: To assess the value of the new ESC criteria including 18F-FDG PET/CT in native valve infective endocarditis (NVIE). 2. Secondary objectives: – to determine the usefulness of PET/CT concerning embolic or neoplastic detection. – to describe a new PET/CT feature, i.e. the diffuse splenic uptake. Methods Between 2012 and 2017, 75 patients with suspected NVIE were prospectively included, after exclusion of patients with uninterpretable or not feasible PET/CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 63 IE were confirmed and 12 were rejected. Patients follow-up was scheduled at one and three months after hospitalization. Results Significant cardiac uptake by PET/CT (major criterion) was observed in 11 among 63 patients with definite NVIE and no patients with rejected IE (sensitivity 18%, specificity 100%). Among the 63 patients with a final diagnosis of NVE, a peripheral embolism or mycotic aneurysm was observed in 20 cases (32%). Considering this, the ESC 2015 classification increased the sensitivity of Duke criteria from 64 to 70% (p Conclusion 1. The value of 18F-FDG PET/CT in NVE diagnosis is poor (18% sensitivity) 2. Usefulness of PET/CT remains high when concerning embolic or neoplastic detection. 3. Our study describes for the first time in NVE a new potential endocarditis criterion, i.e. the presence of a diffuse splenic uptake on 18F-FDG PET/CT Diffuse splenic uptake Funding Acknowledgement Type of funding source: None

International audience; The origin of a cholera outbreak may be unclear, as recently in Algeria. In two patients from North Africa, Vibrio cholerae was isolated in the context of hepatobiliary tract infections without any known outbreak. Gallbladder and asymptomatic long-term carriers might play a role in the emergence of cholera.

ObjectiveThe primary objective was to assess the characteristics and prognosis of pyogenic spondylodiscitis (PS) in patients with infective endocarditis (IE). The secondary objectives were to assess the factors associated with occurrence of PS.MethodsProspective case–control bi-centre study of 1755 patients with definite IE with (n=150) or without (n=1605) PS. Clinical, microbiological and prognostic variables were recorded.ResultsPatients with PS were older (mean age 69.7±18 vs 66.2±14; p=0.004) and had more arterial hypertension (48% vs 34.5%; pStreptococcus gallolyticus were more frequent (24% vs 12% and 24% vs 11%; p18F-FDG PET/CT in 56 patients. In-hospital (16% vs 13.5%, p=0.38) and 1-year (21% vs 22%, p=0.82) mortalities did not differ between patients with or without PS.ConclusionsPS is a frequent complication of IE (8.5% of IE), is observed in older hypertensive patients with enterococcal or S. gallolyticus IE, and has a similar prognosis than other forms of IE. Since PS is associated with specific management, multimodality imaging including MRI, CT and PET/CT should be used for early diagnosis of this complication of endocarditis.

Background Infective endocarditis (IE) is a severe disease requiring early diagnosis and treatment. Although echocardiography (ECHO) is the key diagnostic method, CT-scan (CT) has recently been added as a new ESC diagnostic criterion. However, published data are scarce and included few patients Purpose To assess the additional value of CT over ECHO for the diagnosis of IE Methods Between 2014 and 2017, 246 pts with suspected IE underwent both ECHO and CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 222 IE were confirmed (112 native [NVE] and 110 prosthetic [PVE]) and 24 were rejected. The primary end-point was the comparison between ECHO and cardiac CT (CCT) findings. The secondary end-point was the change in diagnostic criteria sensitivity and specificity associated with the addition of CT results. Results 1. Among the 110 cases of definite PVE, – Vegetations were found in 49 (44%) pts by ECHO and 45 (40%) by CCT (agreement in 71 [64%] pts). – Periannular lesions were found in 33 (30%) pts by ECHO and 46 (41%) by CCT (agreement in 86 [77%] pts). – CCT found a new cardiac lesion missed by ECHO in 10 (9%) pts. 2. Among the 112 cases of definite NVE, – Vegetations were found in 84 (76%) pts by ECHO and 90 (81%) by CCT (agreement in 84 [76%] pts). – Periannular lesions were found in 34 (30%) pts by ECHO and 29 (26%) by CCT (agreement in 58 [52%] pts). – CCT found a new cardiac lesion missed by ECHO in 3 (3%) pts. 3. Including CT findings as major and minor criteria increased the sensitivity of Duke criteria from 60 to 70% in 124 suspected PVE, and from 73 to 80% in 122 suspected NVE, without significant decrease in specificity. Conclusions 1. This study is the largest prospective study assessing the value of CT in the diagnosis of IE. 2. Adding CT findings significantly increases the sensitivity of Duke criteria, both in NVE and PVE. 3. Our results support the use of ESC criteria including CT rather than Duke criteria.

Background and objectives 18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines, but the value of this new diagnostic algorithm has never been prospectively assessed. Purposes 1. Primary objective: to assess the value of the new ESC criteria including 18F-FDG PET/CT in prosthetic valve infective endocarditis (PVIE). 2. Secondary objectives: to determine the reproducibility of 18F-FDG PET/CT; to assess its ability to predict embolic events. Methods Between 2014 and 2017, 175 patients with suspected PVIE were prospectively included in 3 French centers. After exclusion of patients with uninterpretable or not feasible PET/CT,115 patients were finally included in the analysis, including 91 definite IE and 24 rejected IE, as defined by an expert Consensus of Endocarditis Team after 3-month follow-up as Gold Standard Nuclear data were blindly analyzed by two independent nuclear medicine physicians. Patients follow-up was scheduled at one and three months after hospitalization Results Significant cardiac uptake by PET/CT (major criterion) was observed in 67 among 91 patients with definite PVIE and 6 patients with rejected IE (sensitivity 73.6%, specificity 75%, positive predictive value 91%, negative predictive value 42%). Considering cardiac uptake as a major criterion, the ESC 2015 classification increased the sensitivity of Duke criteria from 57 to 84% (p Intraobserver reproducibility of cardiac uptake evaluation was good (kappa = 0.84) but inter observer reproductibility was less satisfactory (kappa = 0.63). Embolic events occurred in 31 patients (27%) and were correlated with vegetation size by ECHO (p Conclusion 1. the value of PET CT and ESC criteria is confirmed and may allow earlier diagnosis of PVIE 2. PET CT is associated with an increased risk of false positive results probably related to the technical improvements 3. Reproducibility of nuclear measurements seems unsatisfactory, justifying efforts to standardize PET studies interpretation 4. Our study describes for the first time a positive correlation between a positive PET/Ct and occurrence of embolic events, warranting additional studies.

Background 18-Fluorodeoxyglucose Positron emission tomography (18F-FDG PET/CT) has been shown to be useful for the diagnosis of IE, but its prognostic value is unknown. Objectives This study sought to assess the prognostic value of 18F-FDG PET/CT in prosthetic (PVE) and native valve endocarditis (NVE). Methods We prospectively studied 173 consecutive patients (109 PVE and 64 NVE) with definite IE who underwent a 18F-FDG PET/CT study and were follow-up for one year. Primary end-point was a composite of major cardiac events i.e. death, recurrence of IE, acute cardiac failure, non-scheduled hospitalization for cardiovascular reason, and new embolic event Results 18F-FDG PET/CT was positive in 98 (57%) patients, 82% (n=88/109) in the PVE and 16% (n=10/64) in the NVE group. At a mean follow of 225±18 days, the primary end-point occurred in 94 (55%) patients, 63 (58%) in the PVE group and 31 (48%) in the NVE group. In the PVE group, positive 18F-FDG PET/CT was significantly associated with higher rate of primary end-point (OR=2.6, IC95%=1.04 to 6.6; p=0.04). Moderate to intense 18F-FDG valvular uptake was also associated with worse outcome (OR=2.1; IC95%=1.1 to 4.0; p=0.03) and to new embolic events, (OR: 8.8; IC95%= 1.1 to 69.5; p=0.02). In the NVE group, 18F-FDG PET/CT was not associated with occurrence of the primary end-point. Conclusion In addition to be an accurate diagnostic tool, 18F-FDG PET/CT is predictive of major cardiac events in PVE and to embolic events during the first year following IE episode

Background Spondylodiscitis (SP) is a rare, but severe complication of infective endocarditis (IE). The incidence, clinical features and prognosis of SP in IE are unknown. Purpose The primary objective of our study was to assess the incidence, epidemiology, clinical presentation, prognosis, and therapeutic implications of SP in patient with IE. The secondary objectives were to assess factors associated with occurrence of spondylitis and to assess the value of imaging techniques. Methods In a French bi-center prospective study of patients who presented in our endocarditis reference centers with a diagnosis of definite IE from 1990 to 2018 (n=1755), 150 (8.5%) presented with SP. Clinical, epidemiological, microbiological, and prognostic variables were prospectively recorded and compared between patients with (n=150) and without (n=1605) SP. Results Patients with SP were older (mean age 69.7±18 vs 66.2±14; p=0.004), had more arterial hypertension (48% vs 34,5%; p Conclusions We describe the largest ever reported series of patients with spondylodiscitis complicating IE. Spondylodiscitis is a more frequent complication of IE than previously reported (8.5% of IE), is observed in older hypertensive patients with Enterococcal or Streptococcus gallolyticus IE and has a similar prognosis than other forms of IE. Since SP is associated with prolonged antibiotic therapy and may need specific surgical therapy, multimodality imaging including MRI, CT, and PET/CT should be used for early diagnosis of this IE complication.

The mortality rate for Staphylococcus aureus endocarditis remains as high as 20-30% despite improvements in medical and surgical treatment. This study evaluated the efficiency and tolerance of a combination of intravenous trimethoprim-sulfamethoxazole and clindamycin (TC) +/- rifampicin and gentamicin, with a rapid switch to oral administration of TC.This before-after intervention study compared the outcomes of 170 control patients before introduction of the TC protocol (2001-2011) with the outcomes of 171 patients in the TC group (2012-2016). All patients diagnosed with S. aureus infective endocarditis and referred to the study centre between 2001 and 2016 were included. Between 2001 and 2011, the patients received a standardized antibiotic treatment: oxacillin or vancomycin for 6 weeks, plus gentamicin for 5 days. Since February 2012, the antibiotic protocol has included a high dose of TC (intravenous, switched to oral administration on day 7). Rifampicin and gentamicin are also given in cases of cardiac abscess or persistent bacteraemia.The two groups were slightly different. On intention-to-treat analysis, global mortality (19% vs 30%, P=0.024), in-hospital mortality (10% vs 18%, P=0.03) and 30-day mortality (7% vs 14%, P=0.05) were lower in the TC group. The mean duration of hospital stay was significantly shorter in the TC group (30 vs 39 days; P=0.005).The management of S. aureus infective endocarditis using a rapid shift to oral administration of TC reduced the length of hospital stay and the mortality rate.

This study sought to assess the prognostic value ofThis study prospectively included 173 consecutive patients (109 PVE and 64 NVE) with definite left-sided IE who had an

International audience

International audience; Background. Staphylococcus aureus prosthetic valve endocarditis (SAPIE) is a serious disease. Aims. Our objective was to study the clinical, echocardiographic and prognostic characteristics of left-sided SAPIE, and to compare these characteristics with those of left-sided non-S. aureus prosthetic infective endocarditis (NSAPIE) (i.e. left-sided prosthetic infective endocarditis caused by another germ). Methods. This was a retrospective analysis of 35 cases of SAPIE among 247 cases of left-sided prosthetic valve endocarditis hospitalized at two university hospitals (Amiens and Marseille, France). Results. SAPIE accounted for 14.1% of the cases of left-sided prosthetic valve endocarditis. SAPIE complications included heart failure (in 42.8% of cases), acute renal failure (in 51.4%), sepsis (in 51.4%), neurological events (in 31.4%), systemic embolic event (in 34.2%) and abscess (in 60.0%). In-hospital mortality occurred in 48.5% of SAPIE cases compared with 16% of NSAPIE cases. A comparison of the SAPIE and NSAPIE groups showed a significant difference in terms of 4-year survival (31.8 +/- 7.3% vs 60.1 +/- 4.1%; P= 0.001). Severe sepsis was the only prognostic factor associated with in-hospital mortality (odds ratio 5.7; P=0.03) and. long-term mortality (odds ratio 3.7; P=0.01) in cases of SAPIE. Sepsis-induced multiple organ dysfunction syndrome was the main cause of in-hospital mortality (70.5%). Conclusions. SAPIE is a very serious disease, with elevated in-hospital mortality resulting from sepsis-induced multiple organ dysfunction syndrome. Emergency surgery is recommended in these cases, when possible, before the occurrence of complications, especially severe sepsis. (C) 2016 Elsevier Masson SAS. All rights reserved.

International audience; Background. - Staphylococcus aureus infective endocarditis (SATE) is a serious and common disease. Aims. - To assess the clinical and echocardiographic characteristics and prognostic factors of left-sided native-valve SATE, and to compare these characteristics between two periods (1990-2000 vs. 2001-2010). Methods. - This was a retrospective analysis of 162 cases of left-sided native-valve SATE among 1254 patients hospitalized for infective endocarditis (IE) between 1990 and 2010. Results. - SATE represented 18.1% of all cases of IE and 22.9% of cases of native-valve IE. Complications included heart failure in 44.7% of cases, acute renal failure in 23.3%, sepsis in 28.5%, neurological events in 35.8%, systemic embolic events in 54.9% and in-hospital mortality in 25.3%. Factors associated with in-hospital mortality were heart failure (odds ratio [OR] 2.5; P=0.04) and sepsis (OR 5.3; P=0.001). Long-term 5-year survival was 49.6 +/- 4.9%. Factors associated with long-term mortality were heart failure (OR 1.7; P=0.032), sepsis (OR 3; P=0.0001) and delayed surgery (OR 0.43; P=0.003). Comparison of the two periods revealed a significant increase in bivalvular involvement, valvular incompetence and acute renal failure from 2001 to 2010. No significant difference was observed in terms of in-hospital mortality rates (28.1% vs. 23.5%; P=0.58) and long-term 5-year survival (45.0 +/- 6.6% vs. 57.1 +/- 6.4%; P=0.33). Conclusion. - Mortality as a result of left-sided native-valve SATE remains high. Factors associated with in-hospital mortality are heart failure and sepsis. Factors associated with long-term mortality are heart failure, sepsis and delayed surgery. Despite progress in surgical techniques, in-hospital mortality and long-term mortality have not decreased significantly between the two periods. (C) 2015 Elsevier Masson SAS. All rights reserved.

We sequenced the genome of Listeria ivanovii strain G770, which caused a deadly infection of the thoracic aortic prosthesis of a 78-year-old man. The 2.9 Mb genome exhibited 21 specific genes among L. ivanovii strains, including five genes encoding a type I restriction modification system and one glycopeptide resistance gene.

Background 18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines. We and others have demonstrated that PET/CT was useful in patients with suspected prosthetic valve and cardiac device IE. However, the sensitivity and specificity of ESC classification is unknown in patients with NVIE. Purposes 1. Primary objective: to assess the value of the new ESC criteria including 18F-FDG PET/CT in native valve infective endocarditis (NVIE). 2. Secondary objectives: – to determine the usefulness of PET/CT concerning embolic or neoplastic detection; – to describe a new PET/CT feature, i.e. the diffuse splenic uptake. Methods Between 2012 and 2017, 75 patients with suspected NVIE were prospectively included, after exclusion of patients with uninterpretable or not feasible PET/CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 63 IE were confirmed and 12 were rejected. Results Significant valvular uptake by PET/CT (major criterion) was observed in 11 among 63 patients with definite NVIE and no patients with rejected IE (sensitivity 18%, specificity 100%). Among the 63 patients with a final diagnosis of NVE, a peripheral embolism or mycotic aneurysm was observed in 20 cases (32%). Considering this, the ESC 2015 classification increased the sensitivity of Duke criteria from 64 to 70% (P Conclusion 1. The value of 18F-FDG PET/CT in NVE diagnosis is poor 2. Usefulness of PET/CT remains high when concerning embolic or neoplastic detection. 3. Our study describes for the first time in NVE a new potential endocarditis criterion, i.e. the presence of a diffuse splenic uptake on PET/CT.

Background Spondyslodiscitis (SP) is a rare but severe complication of infective endocarditis (IE). The indicence, clinical features and prognosis of SP in IE are unknown. Purpose The primary objective of our study was to assess the incidence, epidemiology, clinical presentation, prognosis and therapeutic implications of SP in patient with IE. The secondary objectives were to assess factors associated with occurrence of spondylitis and to assess the value of imaging techniques. Methods In a French bi-center prospective study of patients who presented in our endocarditis reference centers with a diagnosis of definite IE from 1990 to 2018 (n = 1755), 150 (8.5%) presented with SP. Patients were divided in two groups for the analysis: patients with (n = 150) and without (n = 1605) SP. Results Patients with SP were older (mean age 69 ± 18 vs. 66 ± 14, P = 0.004), had more arterial hypertension (48% vs. 33%, P Conclusion We describe the largest ever reported series of patients with SP complicating IE. SP is a more frequent complication of IE than previously reported but has similar prognosis than other forms of IE. Multimodality imaging including MRI, CT and PET/CT should be used for early diagnosis of this IE complication.

Background 18F-Fluorodeoxyglucose Positron Emission Tomography (18F-FDG PET) has been shown to be useful for the diagnosis of infective endocarditis (IE), but its prognostic value remains unknown. Objectives This study sought to assess the prognostic value of 18F-FDG PET/CT in prosthetic (PVE) and native valve endocarditis (NVE). Methods We prospectively studied 173 consecutive patients (109 PVE and 64 NVE) with definite IE who underwent an 18F-FDG PET/CT study and were follow-up for one year. Primary end-point was a composite of major cardiac events i.e. death, recurrence of IE, acute cardiac failure, non-scheduled hospitalization for cardiovascular reason, and new embolic event. Results 18F-FDG PET/CT was positive in 100 (58%) patients, 83% (n = 90/109) in the PVE and 16% (n = 10/64) in the NVE group. At a mean follow of 225 days (199 to 251 days), the primary end-point occurred in 94 (54%) patients, 63 (58%) in the PVE group and 31 (48%) in the NVE group. In the PVE group, positive 18F-FDG PET/CT was significantly associated with higher rate of primary end-point (OR = 2.6, IC95% = 1.04 to 6.6; P = 0.04). Moderate to intense 18F-FDG valvular uptake was also associated with worse outcome (OR = 2.1; IC95% = 1.1 to 4.0; P = 0.03) and to new embolic events, (OR = 7.5; IC95% = 1.24 to 45.2) P = 0.03). In the NVE group, 18F-FDG PET/CT was not associated with occurrence of the primary end-point. Conclusion In addition to be an accurate diagnostic tool, 18F-FDG PET/CT is predictive of major cardiac events in PVE and of embolic events during the first year following IE episode.

Summary Background Although intracranial cerebral haemorrhage (ICH) complicating infective endocarditis (IE) is a critical clinical issue, its characteristics, impact, and prognosis remain poorly known. Aims To assess the incidence, mechanisms, risk factors and prognosis of ICH complicating left-sided IE. Methods In this single-centre study, 963 patients with possible or definite left-sided IE were included from January 2000 to December 2015. Results Sixty-eight (7%) patients had an ICH (mean age 57 ± 13 years; 75% male). ICH was classified into three groups according to mechanism: ruptured mycotic aneurysm (n = 22; 32%); haemorrhage after ischaemic stroke (n = 27; 40%); and undetermined aetiology (n = 19; 28%). Five variables were independently associated with ICH: platelet count Conclusions ICH is a common complication of left-sided IE. The impact on prognosis is dependent on mechanism (haemorrhage of undetermined aetiology). We observed a higher mortality rate in patients who had conservative treatment when cardiac surgery was indicated compared with in those who underwent cardiac surgery.

Diagnosis of infective endocarditis (IE) after transcatheter aortic valve replacement (TAVR) remains difficult to establish using modified Duke criteria. We present the value of multi-imaging approach (European Society of Cardiology [ESC]-2015 modified criteria) [(1)][1] in 16 patients referred for

Supplemental Digital Content is available in the text, Blood culture-negative endocarditis (BCNE) may represent up to 70% of all endocarditis cases, depending on series. From 2001 to 2009, we implemented in our laboratory a multimodal diagnostic strategy for BCNE that included systematized testing of blood, and when available, valvular biopsy specimens using serological, broad range molecular, and histopathological assays. A causative microorganism was identified in 62.7% of patients. In this study from January 2010 to December 2015, in an effort to increase the number of identified causative microorganisms, we prospectively added to our diagnostic protocol specific real-time (RT) polymerase chain reaction (PCR) assays targeting various endocarditis agents, and applied them to all patients with BCNE admitted to the 4 public hospitals in Marseille, France. A total of 283 patients with BCNE were included in the study. Of these, 177 were classified as having definite endocarditis. Using our new multimodal diagnostic strategy, we identified an etiology in 138 patients (78.0% of cases). Of these, 3 were not infective (2.2%) and 1 was diagnosed as having Mycobacterium bovis BCG endocarditis. By adding specific PCR assays from blood and valvular biopsies, which exhibited a significantly greater sensitivity (P

International audience; Objective To describe the characteristics of infective endocarditis (IE) in octogenarians and assess their prognosis. Methods Patients with definite IE hospitalised at a referral centre between July 2008 and July 2013 were prospectively included. A total of 454 patients were divided into three groups: 230 patients under 65 years old, 173 patients between 65 and 80 years old, and 51 patients over 80 years old. The main end point was 1-year mortality. Results One-year mortality was higher in the >= 80 years old group (37.3%) than in the = 80 years old group. Among the >= 80 years old group, 38 patients had theoretical indication for surgery. Mortality was low (6.3%)in the 16 operated patients, but very high (72.7%) in the 22 patients not operated. Even if octogenarians were less often operated, their survival after surgery was excellent like younger patients (93.7%, 89.9% and 90.4%, respectively), whereas the absence of surgery was associated with very poor prognosis. Conclusions IE in octogenarians is a different disease, with Enterococci as the most frequent micro-organisms and with higher mortality than younger patients. ESC recommendations for surgery are less implemented than in younger patients, yielding dramatic mortality in patients not operated despite a theoretical indication for surgery, while operated patients have an excellent prognosis. These results suggest that surgery is underused in octogenarians.

International audience; Despite advances in medical, surgical, and critical care, infective endocarditis (IE) remains associated with considerable morbidity and mortality. We evaluated the performance of the Marseille score, including clinical data and biological tests obtained within 2 h, to identify patients at high risk of IE in order to initiate early antimicrobial treatment. This was secondarily confirmed using modified ESC criteria combined with molecular testing and ((18))fluorodeoxyglucose-positron emission tomography/computed tomography as diagnostic tools. In a prospective cohort study, we enrolled 484 patients with cardiovascular predisposition and clinical suspicion of IE from 2011 to 2013. The final diagnosis was definite IE in 123 patients and possible IE in 107. Marseille score was calculated adding one point for each present parameter (range 0-9). This score includes clinical, epidemiological (male, fever, splenomegaly, clubbing, vascular disease and stroke) and biological criteria (Leucocytes > 10,000/mm3, sedimentation rate (SR) > 50/mm or C reactive protein > 10 mg/L and hemoglobin < 100 g/l). A score of 2 or more performed best in predicting IE in patients with predisposing heart lesions. Sensitivity was better on left-side heart lesions (94%) than on right-side heart lesions (85%) (p = 0.04) and better for valvulopathy (94%) than intra cardiac devices (84%) (p = 0.02). The predictive positive value of prosthetic valves was greater than that of native valves (p = 0.02). Using our simple Marseille score combined with our standardized diagnostic procedures would help improve IE management by focusing on early empiric treatment within 2 h of admission for patients with cardiac predisposition factors.

International audience; Antiphospholipid antibodies (aPL) may occur alone or associated with other diseases. To evaluate aPL, tested as anticardiolipin antibodies (IgG aCL) in infective endocarditis (IE) diagnosis, we investigated their prevalence in a cohort of 651 patients with IE suspicion. aPL was significantly associated with definite IE versus IE-rejected patients. Their mean levels were significantly higher in patients with definite IE versus possible IE. When applied as Duke minor criterion, they were significantly more often positive, and at higher levels, in patients with definite IE than in patients with possible or rejected IE. aPL could be helpful in difficult cases of IE diagnosis.

International audience; OBJECTIVE: Acute coronary syndromes (ACS) are a rare complication of infective endocarditis (IE). Only case reports and small studies have been published to date. We report the largest series of ACS in IE. The aim of our study was to describe the incidence and mechanisms of ACS associated with IE, to assess their prognostic impact and to describe their management. METHODS: In a bicentre prospective observational cohort study, all patients with a definite diagnosis of IE were prospectively included. The incidence, mechanism and prognosis of patients with ACS were studied. RESULTS: Among 1210 consecutive patients with definite IE, 26 patients (2.2%) developed an ACS. Twenty-three patients (88%) had a coronary embolism. Two patients had coronary compression by an abscess or a pseudoaneurysm and one patient had an obstruction of his bioprosthesis and left coronary ostium by a large vegetation. Nineteen (73%) patients with ACS developed heart failure and this complication was 2.5 times more frequent than in patients without ACS (p\textless0.0001). In the ACS population, mortality rate was twice than the population without ACS. CONCLUSIONS: ACS is a rare complication of IE but is associated with an increased risk of heart failure and high mortality rate.

International audience; Coxiella burnetii is an intracellular and fastidious bacterium responsible of acute and persistent Q fever infection. Endocarditis and vascular infections are the most common serious complications of acute Q fever. We report the case of a 63-year-old man that presented a mediastinitis associated with a prosthetic vascular infection. Serological cross-reaction was observed between Coxiella burnetii, the agent of Q fever, and Legionella pneumophila with higher antibodies titer for L. pneumophila (IgG = 1:512) than for C. burnetii (phase I IgG = 1:400). We performed western blot with cross-adsorption that supports the diagnosis of C. burnetii infection. Two weeks later, a positive qPCR and culture for C. burnetii on swab taken from the mediastinal cutaneous fistula confirmed the definitive microbiological diagnosis of Q fever mediastinitis. Cross-reactivity between C. burnetii and Legionella spp. has long been known and should be considered in patients with persistent infections. It is important to establish the definite diagnosis because the antibiotic treatment regimens and duration are significantly different. To the best of our knowledge, we reported here the first case of mediastinitis associated to C. burnetii and we diagnosed this persistent infection despite low anti-C. burnetii phase I IgG levels.

Background Embolic events (EE) are major complications of infective endocarditis (IE). Animal models have demonstrated the benefit of aspirin (ASP) and statins (ST) in their prevention, but clinical studies have given conflicting results. Purpose To evaluate the benefit of prior ASP or ST therapy on embolic risk in patients with IE. Methods In a retrospective study from 2010 to 2016, the impact of daily ASP or ST therapy on admission on the risk of EE in patients with IE was assessed. The primary end point was EE occurring before or during hospitalization. Results Among 529 pts with IE, 135 (25%) were treated by ASP, 130 (24%) were treated by ST at the time of diagnosis. EE occurred in 264 (50%) pts including 242 (46%) before and 61 (11%) after initiation of antibiotics. As compared with the 394 pts without prior ASP therapy, the 135 ASP pts were older (67.8 ± 11 vs. 64.4 ± 16 P = 0.02), had more frequent history of renal failure (P = 0.0008) and presented with less frequent EE [53 (39%) vs. 211 (53%) P = 0.01] and similar hemorrhagic complications (8 (5.9%) vs. 45 (11%) P = NS). As compared with the 399 patients without previous ST therapy, the 130 ST patients were older (63.6 ± 16 vs. 70.2 ± 9 P Conclusions Prior aspirin and statin therapy reduces EE in patients with IE without increasing hemorrhagic risk. Additional prospective studies are warranted to assess the benefit of both therapies in reducing morbidity and mortality in IE.

Background In infective endocarditis (IE), neurological complications (NC) may be a cause of delayed cardiac surgery. However, whether this delay impact prognosis or not is unknown. Purpose To evaluate prognosis in patients presenting IE with NC compared to a control group. To describe the impact of temporary surgical contraindication on patient mortality and evaluate the predictive factors for death among patients with NC. Methods In a prospective single-center study, all patients with IE had a systematic screening for cerebral complication. Six months mortality was compared and in patients presenting NC, prognosis according to surgical status was analyzed. The Cox regression model was used to analyze variables predictive of mortality in case of NC. Results Between 2014 and 2018, 351 patients with a diagnosis of left-sided IE were included. 94 patients (26.8%) presented at least one NC. Fifty-nine patients (17.9%) died in the first 6 months of follow-up. Six-months mortality was not significantly different between patients with NC and the control group (P = 0.6). Regarding patients with NC, mortality was higher in non-operated vs. operated patients when cardiac surgery was indicated (P = 0.02). Forty patients had temporary surgical contraindication due to NC. During the period of surgical contraindication, 7 patients (17.5%) died, 6 patients (15%) presented new embolic event, 12 patients (30%) presented cardiac or septic deterioration. By multivariate analysis, predictive factors for mortality among patients with NC were temporary surgical contraindication (HR 7.36; 95% CI 1.61–33.67; P = 0.01) and existence of mechanical prosthetic valve (HR 16.4; 95% CI 2.22–121.17; P = 0.006). Conclusion With current management of IE, mortality of patients with NC is not higher than in control patients. Patients with temporary surgical contraindication because of NC were high-risk patients: they presented a higher risk of death and frequent major complications while waiting for surgery.

Molecular tools have shown an added value in the diagnosis of infectious diseases, in particular for those caused by fastidious intracellular microorganisms, or in patients receiving antibiotics before sampling. If 16S rDNA amplification had been gradually implemented in microbiology laboratories, specific real-time polymerase chain reaction (PCR) would have permitted an increase in the sensitivity of molecular methods and a reduction of contamination. Herein, we report our experience in the diagnosis of infectious diseases over two years, during which 32,948 clinical samples from 18,056 patients were received from France and abroad. Among these samples, 81,476 PCRs were performed, of which 1,192 were positive. Molecular techniques detected intracellular microorganisms in 31.3 % of respiratory samples, 27.8 % of endocarditis samples and 51.9 % of adenitis samples. Excluding intracellular bacteria, 25 % of the positive samples in this series were sterile in culture. Conventional broad-range PCR permitted the identification of fastidious and anaerobic microorganisms, but specific real-time PCR showed a significant superiority in the diagnosis of osteoarticular infections, in particular for those caused by Kingella kingae and Staphylococcus aureus, and for endocarditis diagnosis, specifically when Streptococcus gallolyticus and Staphylococcus aureus were involved. The sensitivity of conventional broad-range PCR was 62.9 % concerning overall diagnoses for which both techniques had been performed. These findings should lead microbiologists to focus on targeted specific real-time PCR regarding the clinical syndrome. Finally, syndrome-driven diagnosis, which consists of testing a panel of microorganisms commonly involved for each syndrome, permitted the establishment of 31 incidental diagnoses.

Objectives This study sought to determine the value of 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) for diagnosing prosthetic valve endocarditis (PVE). Background The diagnosis of PVE remains challenging. In PVE cases, initial echocardiography is normal or inconclusive in almost 30%, leading to a decreased diagnostic accuracy for the modified Duke criteria. Methods We prospectively studied 72 consecutive patients suspected of having PVE. All of the patients were subjected to clinical, microbiological, and echocardiographic evaluation. Cardiac PET/CT was performed at admission. The final diagnosis was defined according to the clinical and/or pathological modified Duke criteria determined during a 3-month follow-up. Results Thirty-six patients (50%) exhibited abnormal FDG uptake around the site of the prosthetic valve. The sensitivity, specificity, positive predictive value, negative predictive value, and global accuracy were as follows (95% confidence interval): 73% (54% to 87%), 80% (56% to 93%), 85% (64% to 95%), 67% (45% to 84%), and 76% (63% to 86%), respectively. Adding abnormal FDG uptake around the prosthetic valve as a new major criterion significantly increased the sensitivity of the modified Duke criteria at admission (70% [52% to 83%] vs. 97% [83% to 99%], p = 0.008). This result was due to a significant reduction (p l 0.0001) in the number of possible PVE cases from 40 (56%) to 23 (32%). Conclusions The use of 18 F-FDG PET/CT was helpful for diagnosing PVE. The results of this study support the addition of abnormal FDG uptake as a novel major criterion for PVE.

Background Immunoglobulin G (IgG) anticardiolipin (aCL) antibodies are associated with valvulopathy and endocarditis in patients with lupus and other diseases. During acute Q fever, high IgG aCL prevalence has been reported, but the clinical significance remains unknown. Methods To test if increased IgG aCL at acute Q fever diagnosis is associated with an increased risk of progression to endocarditis, all patients diagnosed in the French National Referral Center for Q fever from January 2007 to December 2011 were included and followed regularly until January 2013 in a 5-year prospective cohort study. Q fever endocarditis was defined according to recently updated criteria. Results Seventy-two patients were followed for a median time of 31 months (interquartile range, 18-47 months). Of these, 13 patients with valvulopathy without antibiotic prophylaxis progressed to endocarditis. IgG aCL levels were highly prevalent (57%) and significantly higher in the presence of a valvulopathy (P = .005). Using Cox regression analysis, highly increased levels of IgG aCL (adjusted hazard ratio [AHR], 12.95; 95% confidence interval, 2.85-58.95; P = .001) and high levels of phase II immunoglobulin M (IgM; AHR, 6.59; 95% CI, 1.37-31.62; P = .018) were the only independent predictors of progression to endocarditis. Conclusions Rapid progression from acute Q fever to endocarditis is associated with high levels of IgG aCL and high levels of phase II IgM, findings that should be critical in the prevention of endocarditis.