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Positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG) has recently emerged as an increasingly used alternative and supplementary imaging modality for the diagnosis of infective endocarditis. 18F-FDG PET/CT imaging for IE is given a Class I recommendation (level of evidence B) and is therefore recommended in cases of possible prosthetic valve IE to both detect valvular lesions, as well as confirm the diagnosis of IE. They have also given a class I recommendation (level of evidence B) for brain and whole-body 18F-FDG PET/CT and/or MRI imaging to detect peripheral lesions for patients with either native or prosthetic valve IE. Molecular imaging is playing an increasingly important role in the diagnosis and management of patients with IE. The important role of 18F-FDG PET/CT imaging has been acknowledged by recent guideline updates. These advanced imaging tests are not supplanting the role of echocardiography in the diagnostic pathway for IE. Rather, they are additional tools that are available where the diagnosis is complicated, difficult, or uncertain. [ABSTRACT FROM AUTHOR]

The ESC diagnostic criteria for infective endocarditis (IE) added spondylodiscitis as a minor criterion. This resulted in that 11 of 1807 patients with Staphylococcus aureus , streptococcal, or Enterococcus faecalis bacteremia, were reclassified from possible to definite IE, of whom only two were treated as IE. [ABSTRACT FROM AUTHOR]

Background The 2023 Duke–International Society for Cardiovascular Diseases (ISCVID) criteria for infective endocarditis (IE) were proposed as an updated diagnostic classification of IE. Using an open prospective multicenter cohort of patients treated for IE, we compared the performance of these new criteria to that of the 2000 Modified Duke and 2015 European Society of Cardiology (ESC) criteria. Methods Cases of patients treated for IE between January 2017 and October 2022 were adjudicated as certain IE or not. Each case was also categorized as either definite or possible/rejected within each classification. Sensitivity, specificity, and accuracy were estimated with 95% confidence intervals. Results Of the 1194 patients analyzed (mean age, 66.1 years; 71.2% males), 414 (34.7%) had a prosthetic valve and 284 (23.8%) had a cardiac implanted electronic device (CIED); 946 (79.2%) were adjudicated as certain IE; 978 (81.9%), 997 (83.5%), and 1057 (88.5%) were classified as definite IE in the 2000 modified Duke, 2015 ESC, and 2023 Duke–ISCVID criteria, respectively. The sensitivity of each set of criteria was 93.2% (95% confidence interval [CI], 91.6–94.8), 95.0% (95% CI, 93.7–96.4), and 97.6% (95% CI, 96.6–98.6), respectively (P <.001 for all 2-by-2 comparisons). Corresponding specificity rates were 61.3% (95% CI, 55.2–67.4), 60.5% (95% CI, 54.4–66.6), and 46.0% (95% CI, 39.8–52.2), respectively. In patients without CIED, sensitivity rates were 94.8% (95% CI, 93.2–96.4), 96.5% (95% CI, 95.1–97.8), and 97.7% (95% CI, 96.6–98.8); specificity rates were 59.0% (95% CI, 51.6–66.3), 56.6% (95% CI, 49.3–64.0), and 53.8% (95% CI, 46.3–61.2), respectively. Conclusions Overall, the 2023 Duke–ISCVID criteria had a significantly higher sensitivity but a significantly lower specificity compared with older criteria. This decreased specificity was mainly attributable to patients with CIED. [ABSTRACT FROM AUTHOR]

In September 2023, the European Society of Cardiology (ESC) published new guidelines for the management of endocarditis. Infective endocarditis (IE) remains a significant life-threatening disease, concerning an increasingly younger age group, especially children with congenital heart disease (CHD) and young adults after multiple cardiac surgeries. This study's aim was to alert the medical community to the problem of increasing IE case numbers and IE course complexity. Of the eight patients who suffered from IE treated in 2023 in our department, we describe the four whose course was the most extraordinary. Afterward, we compared the number of IE patients treated over the years in our department. All cases described children with congenital heart disease suffering from IE. The IE clinical presentation in all patients was extremely diverse, necessitating the utilization of all available diagnostic methods. Each child underwent specialized treatment and subsequently qualified for cardiac surgery. While the etiology and treatment of IE are well established, it remains a formidable challenge for physicians. Pediatric patients who have undergone multiple cardiac surgeries constitute a steadily expanding group and are especially susceptible to IE throughout their lives. Currently, no recommendations exist for the management of endocarditis in pediatric patients. This gap compels pediatricians to adapt existing guidelines designed for adult patients and to rely on scientific reports, such as case studies. [ABSTRACT FROM AUTHOR]

Aims We aimed to assess the role of multimodality imaging (MMI) in the diagnosis of marantic endocarditis (ME) associated with cancers and to describe the clinical characteristics, management, and outcome of these patients. Methods and results In a retrospective multicentric study including four tertiary centres for the treatment of endocarditis in France and Belgium, patients with a diagnosis of ME were included. Demographic, MMI [echocardiography, computed tomography (CT), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)], and management data were collected. Long-term mortality was analysed. Between November 2011 and August 2021, 47 patients with a diagnosis of ME were included. Mean age was 65 ± 11 years. ME occurred in 43 cases (91%) on native valves. Vegetations were detected by echocardiography in all cases and in 12 cases (26%) by CT. No patient had an increased cardiac 18F-FDG valve uptake. The most common cardiac valve involved was aortic (34 cases, 73%). Twenty-two patients (46%) had a known cancer before ME, and 25 cases (54%) were diagnosed thanks to multimodality imaging. 18FDG PET/CT was performed in 30 patients (64%) and allowed a new diagnosis of cancer in 14 patients (30%). Systemic embolism was frequent (40 patients, 85% of cases). Forty-one patients (87%) were treated medically with anticoagulation therapy. One-year mortality was 55% (26 patients). Conclusion ME remains associated with a high risk of complications and death. [ABSTRACT FROM AUTHOR]

Background: Aerococcus urinae infection is a rare clinical condition that causes urinary tract infections in older individuals. Infective endocarditis (IE) caused by A. urinae in healthy young men is extremely rare; however, the mortality rates of IE caused by A.urinae are high if appropriate surgical treatment is not performed. Case presentation: A 39-year-old healthy man was admitted to our hospital with complaints of fever, cough, and dyspnea. Blood cultures revealed gram-positive cocci, and echocardiography revealed a 20 × 12-mm vegetation on the aortic valve and perforation of the anterior mitral valve leaflet. He was diagnosed with IE and underwent aortic valve replacement and mitral valve repair after removal of the infective focus. Matrix-assisted laser desorption ionization time-of-flight mass spectrometry was used to identify A. urinae. The patient was discharged in good health after 6 weeks of ampicillin/sulbactam therapy. Conclusion: Prompt diagnosis and surgical removal of infectious foci with optimal antibacterial therapy are critical to protect patients from rare and potentially fatal IE caused by A. urinae. [ABSTRACT FROM AUTHOR]

Introduction: Internal carotid artery occlusion as a result of a septic embolism is a rare, commonly fatal, complication of mitral valve infectious endocarditis. Prompt recognition of this condition by the emergency physician may improve the chance of functional neurological survival. Case Report: A 50-year-old male presented minimally responsive with a right gaze deviation, left hemiparesis, and a score of 26 on the National Institutes of Health Stroke Scale. A point-of-care echocardiogram showed a large mitral valve vegetation, and computed tomography angiography demonstrated an internal carotid artery occlusion. Conclusion: The emergency physician should consider this potentially life-threatening condition and know the fundamental management recommendations once identified. [ABSTRACT FROM AUTHOR]

Copyright of Hamidiye Medical Journal is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Infective endocarditis (IE) has various cardiac and extracardiac complications, which include metastatic abscesses of the solid organs such as the liver, kidney, brain, and spleen. Splenic abscess in IE is an uncommon entity, and spontaneous rupture of a large abscess in a newly diagnosed patient with IE is infrequently described in the literature. A 42-year-old male presented to us with a fever and worsening pain in his left upper quadrant. A detailed evaluation led to the diagnosis of IE and a large pyogenic splenic abscess. The blood culture had a growth of Escherichia coli. He was managed initially with intravenous antibiotics, but an urgent laparotomy and splenectomy were undertaken as he deteriorated and developed shock. Unfortunately, despite a prompt surgical intervention, he succumbed to the illness due to persistent postoperative shock. The case describes the catastrophic complications of IE and broadens the understanding of its complication spectrum. [ABSTRACT FROM AUTHOR]

Introduction: Seasonal variation has been observed for bacterial and viral infections (e.g., COVID-19 [1]), but also for numerous cardiac problems. However, little information is available on the seasonality of infectious endocarditis (IE), a rare disease that is usually linked to a bacterial origin. Data from the Polish population are lacking. Materials and Methods: Our retrospective study focused on the identification of patients with IE, who were hospitalized at the University Hospital in Krakow between 2005-2022. For this purpose, we searched the medical records system using the ICD-10 code. We decided to divide our patients into four groups (winter, spring, summer, autumn), based on the date of admission to the hospital. Comparison of the distribution of IE incidents by season was performed with the ch2 test. Results: One hundred and ten patients were included in the study (median age 62.5 years (range 20-94), 72 men (65.45%)). The left native valve IE was diagnosed in 49% of the patients, the prosthetic valve IE in 16%, the right valve IE in 27% and the implantable cardiac electronic devices IE in 12% of the subjects. The outcomes comprised of cardiac surgery (n = 53), embolism (n = 16), death (n = 15) and metastatic infections (n = 5). No differences in the incidence of IE by season were observed. Conclusions: In the preliminary observation of IE cases of patients admitted to the University Hospital in Krakow, Poland no seasonal pattern of IE was detected. Therefore, IE should be taken into account in the differential diagnosis at any time of the year. [ABSTRACT FROM AUTHOR]

Copyright of Bagcilar Medical Bulletin / Bağcılar Tıp Bülteni is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Hemodialysis patients are at high risk for prosthetic valve endocarditis (PVE) because of the risk of bacteria entering with each hemodialysis session. To avoid the use of artificial materials as much as possible, we performed aortic valve neocuspidization (AVNeo) using bovine pericardium. Case presentation: A 67-year-old patient had undergone aortic valve replacement using a bioprosthetic valve 4 months previous. For the past month, he had had PVE caused by Candida glabrata. Because the pericardium had already been incised in the previous surgery and there was not enough pericardium left for neocuspidization, we performed AVNeo using bovine pericardium. The previously implanted bioprosthetic valve revealed sticky fungal warts on the leaflet and valve ring, which prevented the movement of the valves. We cut all of the threads holding the valve and removed the bioprosthetic valve. Three valves were cut from the bovine pericardium using a unique template following the method of Ozaki et al. and were fixed to the valve ring with a running suture. The postoperative course was good. Conclusions: We believe that this treatment is an effective method for PVE because we can avoid the use of artificial materials as much as possible. [ABSTRACT FROM AUTHOR]

Aim: Cardiac implantable electronic device infective endocarditis is a serious infection with poor prognosis. Materials & methods: The systematic review of the literature was conducted using searches from the various databases. We included studies published between January 2010 and June 2021. Results: A total of 35 articles met the inclusion criteria. Patients were approximately 70 years old and an average of 71.2% of patients were male. The most common presenting feature was a fever. The modified Duke criteria was used to aid diagnosis. Management entailed extraction of the cardiac implantable electronic device in 80.5% of the studies. The overall mortality rates ranged from 4 to 36%. The most frequently isolated organism was Staphylococcus aureus. Conclusion: Cardiac implantable electronic device infective endocarditis needs timely diagnosis and effective management for promising outcomes. [ABSTRACT FROM AUTHOR]

Diagnosis of infective endocarditis (IE) remains a clinical challenge. Transthoracic echocardiogram (ECHO) (TTE) and positron emission tomography (PET) scans have limitations. We report this case of endocarditis where two-dimensional (2D) ECHO and PET scan were nondiagnostic on initial evaluation, and the organism grown on blood culture was probably misidentified. The patient was subsequently diagnosed with mitral valve endocarditis and was started on definitive antimicrobial therapy. [ABSTRACT FROM AUTHOR]

In the era of coronavirus disease 2019 (COVID‐19), the management of cardiac implantable electronic devices infections with concomitant viral infection has not been completely defined yet. In this explorable context, we report the first experience of a Cardiac resynchronization therapy with defibrillator (CRT‐D) implantation after transvenous lead extraction for endocarditis in a COVID‐19 patient. We describe both the measures and procedures implemented to reduce the cross‐infection in the operating room and our clinical practice to improving procedure effectiveness on patient care. [ABSTRACT FROM AUTHOR]

Amidst a substance use epidemic, hospitalizations and valve surgeries related to drug use-associated infective endocarditis (DU-IE) rose substantially in the last decade. Rates of reoperation and mortality remain high, yet in many hospitals patients are not offered valve surgery or evidence-based addiction treatment. A multidisciplinary team approach can improve outcomes in patients with infective endocarditis; however, the breadth of expertise that should be incorporated into this team is inadequately conceptualized. It is our opinion that incorporating addiction medicine services into the team may improve outcomes in DU-IE. Here, we describe our experience incorporating addiction medicine services into the multidisciplinary management of DU-IE and share implications for other hospitals and health systems looking to improve care for people with DU-IE. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Minimally invasive surgery of the ascending aorta has been becoming increasingly popular. For this purpose, the most frequently used incisions are mini-sternotomy and right anterior mini-thoracotomy. We report a new approach that can be safely performed in ascending aorta and/or aortic root pathologies through right infra-axillary vertical mini-thoracotomy. Methods: While implementing this approach, it was taken into account that our first patient did not have active endocarditis and had not undergone cardiac surgery before. He had dialysis dependent chronic kidney disease and his predicted mortality rate by EuroSCORE II was 5.27 %. The infra-axillary mini-thoracotomy was performed through a 8-cm vertical skin incision centering the right fourth intercostal space on the anterior axillary line. Results: The patient was 63 years old. He was undergone the Bentall procedure using an aortic valve bioprosthesis implanted in 30 mm - Dacron tube graft. Cardiopulmonary bypass time and median cross-clamp time were 106 minutes and 169 minutes, respectively. No morbidity or complication was observed. Conclusions: The Bentall procedure with a minimally invasive approach using a right vertical infraaxillary mini-thoracotomy can be a safe alternative to the standard in selected patients presenting with ascending aortic and/or complex aortic root pathologies. [ABSTRACT FROM AUTHOR]

Background The spectrum of infections caused by methanogens remains to be described. We searched for methanogens in the blood of febrile patients using specific tools. Methods Blood culture samples routinely collected in patients with fever were prospectively screened by specific PCR assays for methanogens. Positive samples were observed by autofluorescence and electron microscopy, analyzed by metagenomics and cultured using previously developed methods. Blood culture bottles experimentally inoculated were used as controls. The presence of methanogens in vascular and cardiac tissues was assessed by indirect immunofluorescence, fluorescent in situ hybridization and PCR-based investigations. Results PCR detection attempted in 7,716 blood samples, was negative in all 1,312 aerobic bottles and 810 bacterial culture-negative anaerobic bottles. PCRs were positive in 27/5,594 (0.5%) bacterial culture-positive anaerobic bottles collected from 26 patients. Sequencing confirmed Methanobrevibacter smithii associated with staphylococci in 14 patients, Enterobacteriaceae in nine patients and streptococci in three patients. Metagenomics confirmed M. smithii in five samples, and M. smithii was isolated in broth from two samples; the genomes of these two isolates were sequenced. Blood cultures experimentally inoculated with Enterobacteriaceae, Staphylococcus epidermidis or Staphylococcus hominis yielded hydrogen, but no methane, authentifying observational data. Three patients diagnosed with infectious mitral endocarditis, were indisputably diagnosed by microscopy, PCR-based detections and culture: we showed M. smithii microscopically and by a specific PCR followed by sequencing method in two of three cardiovascular tissues. Conclusions Using appropriate laboratory methods, M. smithii is demonstrated as causing archaemia and endocarditis in febrile patients who are coinfected by bacteria. [ABSTRACT FROM AUTHOR]

Introduction: Sex-dependent differences of infective endocarditis (IE) have been reported. Women suffer from IE less frequently than men and tend to present more severe manifestations. Our objective was to analyse the sex-based differences of IE in the clinical presentation, treatment, and prognosis.Material and Methods: We analysed the sex differences in the clinical presentation, modality of treatment and prognosis of IE in a national-level multicentric cohort between 2008 and 2018. All data were prospectively recorded by the GAMES cohort (Spanish Collaboration on Endocarditis).Results: A total of 3451 patients were included, of whom 1105 were women (32.0%). Women were older than men (mean age, 68.4 vs 64.5). The most frequently affected valves were the aortic valve in men (50.6%) and mitral valve in women (48.7%). Staphylococcus aureus aetiology was more frequent in women (30.1% vs 23.1%; p<0.001).Surgery was performed in 38.3% of women and 50% of men. After propensity score (PS) matching for age and estimated surgical risk (European System for Cardiac Operative Risk Evaluation II (EuroSCORE II)), the analysis of the matched cohorts revealed that women were less likely to undergo surgery (OR 0.74; 95% CI 0.59 to 0.91; p=0.05).The observed overall in-hospital mortality was 32.8% in women and 25.7% in men (OR for the mortality of female sex 1.41; 95% CI 1.21 to 1.65; p<0.001). This statistical difference was not modified after adjusting for all possible confounders.Conclusions: Female sex was an independent factor related to mortality after adjusting for confounders. In addition, women were less frequently referred for surgical treatment. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) is among the most fatal infectious diseases. Since the introduction of various intracardiac devices and interventions, the clinical aspects of IE have rapidly evolved. In this paper, we aim to define the contemporary characteristics of patients diagnosed with definite IE and to identify the predictors associated with mortality. Through retrospective analysis of patients with TEE proven vegetation, those fulfilling the modified Duke criteria for definite IE were identified. Patient characteristics in relation to clinical outcomes and mortality were analyzed. Out of 50 patients (mean age 57±15.9 years, 34% female), 72% was native-valve endocarditis of which only 32% had a predisposing valve disease such as rheumatic valve. The rate of prosthetic-valve IE was 10% and that of device-related IE was 18%. The most common causative organisms were S. aureus (16%), Coagulase-negative Staphylococci (16%), Enterococci (14%) and Viridans streptococci (12%). In-hospital mortality was 24% and was associated with concomitant diabetes, coronary artery disease, higher baseline creatinine, anemia, occurrence of cranial complications and absence of surgery during the index hospitalization. Regression analyses revealed that cerebral emboli were the only predictor of early mortality, possibly through delayed surgical treatment. In conclusion, our small cohort of definite IE patients showed that contemporary characteristics of IE has evolved with higher rates of device-related IE. Within established prognostic factors, cerebral emboli and timing of surgery are intervening factors, which suggests that the timing of surgical treatment, particularly in patients with neurologic complications, needs to be evaluated when shaping future perspectives on IE. [ABSTRACT FROM AUTHOR]

Background and Aims: Opioid use disorder (OUD) has led to not only increases in overdose deaths, but also increases in endocarditis and osteomyelitis secondary to injection drug use (IDU). We studied the association between initiation of medications for opioid use disorder (MOUD) and treatment outcomes for people with infectious sequelae of IDU and OUD. Design and setting: This is a retrospective cohort study reviewing encounters at 143 HCA Healthcare hospitals across 21 states of the United States from 2014 to 2018. Participants Adults aged 18–65 with the ICD diagnosis code for OUD and endocarditis or osteomyelitis (n = 1407). Measurements Main exposure was the initiation of MOUD, defined as either methadone or buprenorphine at any dosage started during hospitalization. Primary outcomes were defined as patient‐directed discharge (PDD), 30‐day re‐admission and days of intravenous antibiotic treatment. Covariates included biological sex, age, ethnicity, other co‐occurring substance use disorders, and insurance status. Findings MOUD was initiated among 269 (19.1%) patients during hospitalization. Initiation of MOUD was not associated with decreased odds of PDD. Initiation of MOUD did not impact 30‐day re‐admission. Patients who received MOUD, on average, had 5.7 additional days of gold‐standard intravenous antibiotic treatment compared with those who did not [β = 5.678, 95% confidence interval (CI) = 3.563, 7.794), P < 0.05]. Conclusion: For people with opioid use disorder hospitalized with endocarditis or osteomyelitis, initiation of methadone or buprenorphine appears to be associated with improved receipt of gold‐standard therapy, as quantified by increased days on intravenous antibiotic treatment. [ABSTRACT FROM AUTHOR]

Background Diagnostic and patients' management modifications induced by whole-body 18F-FDG-PET/CT had not been evaluated so far in prosthetic valve (PV) or native valve (NV) infective endocarditis (IE)-suspected patients. Methods In sum, 140 consecutive patients in 8 tertiary care hospitals underwent 18F-FDG-PET/CT. ESC-2015-modified Duke criteria and patients' management plan were established jointly by 2 experts before 18F-FDG-PET/CT. The same experts reestablished Duke classification and patients' management plan immediately after qualitative interpretation of 18F-FDG-PET/CT. A 6-month final Duke classification was established. Results Among the 70 PV and 70 NV patients, 34 and 46 were classified as definite IE before 18F-FDG-PET/CT. Abnormal perivalvular 18F-FDG uptake was recorded in 67.2% PV and 24.3% NV patients respectively (P <.001) and extracardiac uptake in 44.3% PV and 51.4% NV patients. IE classification was modified in 24.3% and 5.7% patients (P =.005) (net reclassification index 20% and 4.3%). Patients' managements were modified in 21.4% PV and 31.4% NV patients (P =.25). It was mainly due to perivalvular uptake in PV patients and to extra-cardiac uptake in NV patients and consisted in surgery plan modifications in 7 patients, antibiotic plan modifications in 22 patients and both in 5 patients. Altogether, 18F-FDG-PET/CT modified classification and/or care in 40% of the patients (95% confidence interval: 32–48), which was most likely to occur in those with a noncontributing echocardiography (P <.001) or IE classified as possible at baseline (P =.04), while there was no difference between NV and PV. Conclusions Systematic 18F-FDG-PET/CT did significantly and appropriately impact diagnostic classification and/or IE management in PV and NV-IE suspected patients. Clinical Trials Registration NCT02287792. [ABSTRACT FROM AUTHOR]

Copyright of Revista Española de Quimioterapia is the property of Sociedad Espanola de Quimioterapia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Nonbacterial thrombotic endocarditis, or marantic endocarditis, is rare. Contemporary data on the etiology, echocardiographic evaluation, and management of nonbacterial thrombotic endocarditis are limited.Methods: A single-center retrospective cohort study was performed. Electronic medical records and echocardiographic records were searched for patients ages ≥18 years with a confirmed diagnosis of nonbacterial thrombotic endocarditis between January 1999 and November 2019. Demographic, echocardiographic, and management data were collected.Results: Of 600,577 transthoracic echocardiograms (TTEs) and 89,264 transesophageal echocardiograms (TEEs), 42 patients had nonbacterial thrombotic endocarditis (mean age: 54 ± 14.5 years; 66.7% were female). The median duration of follow-up was 8.2 (interquartile range 3.3-24.4) months. Seventeen patients (40.5%) had malignancy, 33.3% had systemic lupus erythematosus, and 35.7% had antiphospholipid antibody syndrome. Stroke was the most common presentation (59.5%). TTE enabled the diagnosis in 19 cases (45.2%), compared with TEE, which identified the condition in 33 of 34 (97.1%) cases in which it was utilized. Three-dimensional echocardiography was performed in 17 TEEs. The most common valves involved were mitral (61.9%), and aortic (23.8%) valves. Thirty-two patients were managed with anticoagulation. Ten patients underwent surgery. Sixteen (38.1%) patients died, most of whom had a diagnosis of advanced malignancy.Conclusion: In a contemporary 20-year cohort, TTE and TEE played important roles in diagnosis, with superior diagnostic performance of TEE for nonbacterial thrombotic endocarditis. Mortality was high, and advanced malignancy portended a worse prognosis. Management in most cases was therapeutic anticoagulation. In select cases, surgery provided favorable outcomes. [ABSTRACT FROM AUTHOR]

Background: Patients who present to the hospital for infectious complications of intravenous opioid use are at high risk for against-medical-advice discharge and readmissions. The role of medication-assisted treatment for inpatients is not clear. We aimed to assess outcomes prior to and after rollout of an inpatient buprenorphine-based opioid use disorder protocol, as well as to assess outcomes in general for medication-assisted therapy.Methods: This was a retrospective observational cohort study at our community hospital in New Hampshire. The medical record was searched for inpatients with a complication of intravenous opioid use. We searched for admissions 11 months prior to and after the November 2018 buprenorphine protocol rollout.Results: Rates of medication-assisted therapy usage and buprenorphine linkage increased significantly after protocol rollout. Rates of against-medical-advice discharge did not decrease after protocol rollout, nor did readmissions. However, when evaluating the entire group of patients regardless of date of presentation or protocol use, against-medical-advice discharge rates were substantially lower for patients receiving medication-assisted therapy compared with those receiving supportive care only (30.0% vs 59.6%). Readmissions rates were lower for patients who were discharged with any form of ongoing medication-assisted therapy compared with those who were not (30-day all-cause readmissions 18.8% vs 35.1%; 30-day opioid-related readmissions 10.1% vs 29.9%; 90-day all-cause readmissions 27.3% vs 42.7%; 90-day opioid-related readmissions 15.1% vs 33.3%).Conclusions: There is a strong association between medication-assisted therapy and reduced against-medical-advice discharge rates. Additionally, maintenance medication-assisted therapy at time of discharge is strongly associated with reduced readmissions rates. [ABSTRACT FROM AUTHOR]

Background: Healthcare systems and public health agencies use different methods to measure the impact of substance use (SU) on population health. We studied the ability of systems to accurately capture data on drug use-associated infective endocarditis (DUA-IE).Methods: We conducted a retrospective analysis of patients with IE discharge diagnosis from an academic medical center, 2011-2017, comparing data from hospital Electronic Health Record (EHR) to State Uniform Hospital Discharge Data Set (UHDDS). To identify SU we developed a composite measure.Results: EHR identified 472 IE discharges (430 of these were captured in UHDDS); 406 (86.0%) were correctly coded based on chart review. IE discharges increased from 57 to 92 (62%) from 2012 to 2017. Hospitalizations for the subset of DUA-IE identified by any measure of SU increased from 10 to 54 (440%). Discharge diagnosis coding identified 128 (60.7%) of total DUA-IE hospitalizations. The composite measure identified an additional 65 (30.8%) DUA-IE hospitalizations and chart review an additional 18 (8.5%).Conclusions: The failure of discharge diagnosis coding to identify DUA-IE in 40% of hospitalizations demonstrates the need for better systems to capture the impact of SU. Collaborative data sharing could help improve surveillance responsiveness to address an emerging public health crises. [ABSTRACT FROM AUTHOR]

Background Coronary artery emboli can occur from a number of rare causes such as arterial thrombo-embolus or septic embolus. This diagnosis generally requires multi-modal imaging including echocardiography, computed tomography, or invasive coronary angiography. Septic coronary emboli is an extremely rare consequence of infective endocarditis (IE), having been reported in <1% of all cases. Case summary A 54-year-old previously healthy Tibetan monk presented feeling generally unwell and lethargic. Electrocardiogram demonstrated sinus rhythm, third-degree atrioventricular block with a left bundle branch escape. Initial transthoracic and transoesophageal echocardiography demonstrated vegetations on the aortic and tricuspid valve as well as intra-myocardial abscess. Coronary angiography revealed septic embolus involving the septal perforator coronary artery. He underwent surgical replacement of the infected valves and debridement and repair of a ventricular septal defect. Discussion Infective endocarditis can predispose to a range of cardiac pathology. This case demonstrates that patients can present with cardiac conduction disease from a septic embolus involving a coronary artery as a complication of IE. [ABSTRACT FROM AUTHOR]

Background The incidence of infective endocarditis (IE) following a MitraClip is rare with 17 reported cases in the literature. The reported mortality rate is high, at 41%, despite both medical and surgical therapies. To date, this is the first documented case of IE following a MitraClip procedure in Australia. Case summary An 88-year-old male presented with a 1-week history of confusion and dyspnoea. Clinical examination was significant for a temperature of 37.7°C, a pansystolic murmur and bilateral pitting oedema to mid-shin, but no peripheral stigmata of IE. His history included a MitraClip procedure 11 weeks prior for severe mitral regurgitation. Initial blood cultures grew enterococcus faecalis. A transthoracic echocardiogram did not identify vegetations on the MitraClip. Subsequent transoesophageal echocardiogram (TOE) identified a 4 mm × 2 mm echodensity on the posterior mitral valve leaflet suggestive of IE. He was deemed not suitable for surgical intervention due to poor cognitive reserve and his medical comorbidities, so he commenced intravenous (IV) Ampicillin and Ceftriaxone which was later changed to Benzylpenicillin. Repeat TOE 2 weeks later showed the vegetation to have increased to ∼1 cm in length, so his treatment was reverted to Ampicillin. A further TOE 4 weeks later showed reduction in size to 5 mm × 2 mm. After 6 weeks of IV antibiotics, the patient was discharged on lifelong oral antibiotics. Discussion Infective endocarditis following MitraClip procedure is rare. This disease has a high mortality rate despite optimal medical and surgical therapy. Increased awareness amongst clinicians is important given an increasing volume of MitraClip procedures. [ABSTRACT FROM AUTHOR]

Background Infective endocarditis (IE) secondary to rat-bite fever (RBF) is rare but potentially lethal. Rapid diagnosis is of utmost prognostic importance. However, the diagnosis of RBF is challenging because Streptobacillus moniliformis does not grow under conventional culture conditions. Case summary A 65-year-old male without previous cardiac history presented with sudden onset of balance problems and facial palsy. For 2 weeks, he had experienced intermittent fever and myalgia. Transoesophageal echocardiography (TOE) revealed severe mitral and aortic valve IE with aortic root abscess. The patient underwent a double biological valve replacement. Blood cultures remained negative after 9 days of incubation. However, sub-cultivation on solid media demonstrated the growth of pleomorphic Gram-negative rods, identified as S. moniliformis. After 4 weeks of antibiotic therapy, he was discharged. One month later, control TOE showed valve excrescences and aortic annular aneurysm. Despite comprehensive surgery, antibiotic treatment, and intensive care, the patient died 1 week after reoperation. Discussion A fatal outcome of S. moniliformis IE is rare. The majority of previous cases describe underlying valvular abnormalities or death due to insufficient antimicrobial therapy. Here, the patient had no prehistory of valvular heart disease and despite appropriate antibiotics, the outcome was fatal. Rapid diagnosis of RBF IE has prognostic implications. Identification of S. moniliformis is, however, difficult, because the bacterium is fastidious and does not grow under standard laboratory conditions. Therefore, diagnosis often relies on clinical symptoms or a history of rodent exposure. Close attention to this disease by clinicians, in addition to, dialogue with clinical microbiologists is essential. [ABSTRACT FROM AUTHOR]

Background Transcatheter aortic valve replacement (TAVR) is becoming increasingly utilized for the treatment of severe aortic valvular heart disease. Infective endocarditis of TAVR is rare but associated with higher mortality and morbidity. The potential for leaflet thrombosis following TAVR is also becoming increasingly recognized. Diagnosis of these conditions on echocardiography can be challenging due to prosthesis artefact. Case summary An 84-year-old man with a previous transcatheter aortic valve replacement presented with a febrile illness and bacteraemia. Transthoracic and transoesophageal echocardiography demonstrated high transvalvular gradients with features of prosthesis endocarditis, though leaflet morphology could not be fully assessed due to prosthesis artefact. Four-dimensional computed tomography revealed hypo-attenuated leaflet thickening with reduced leaflet motion, consistent with prosthesis leaflet thrombosis. The patient was successfully treated with antibiotics and anticoagulation, with resolution of the infection and normalization of the transvalvular gradient after 6 weeks. Discussion Echocardiography should be the first-line investigation for assessing leaflet morphology in suspected prosthetic valve endocarditis or leaflet thrombosis but its accuracy may be limited by artefact. Our case highlights that four-dimensional computed tomography provides further evaluation of prosthesis leaflet morphology/motion, providing valuable diagnostic information. [ABSTRACT FROM AUTHOR]

Background Severe mitral regurgitation (MR) through the body of the anterior mitral leaflet (AML) is rare. The cause either iatrogenic during open-heart surgery or due to infective endocarditis. We present a case where a successful percutaneous closure of the AML perforation was an alternative to surgery. Case summary A 60-year-old male presented with shortness of breath (SOB) class III of 12 months duration. He underwent coronary artery bypass surgery with four grafts plus mitral valve (MV) repair 20 months ago. Transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE) revealed severe MR through the body of AML at A3. The percutaneous closure plan was to cross the AML perforation from the left ventricular side. The venacontracta of the perforation was 6 mm, an amplatzer septal occluder device 6 mm considered appropriate for closure of this hole. A snare catheter snared the wire and exteriorized creating arteriovenous loop. Amplatzer septal occluder 6 mm loaded to the delivery system till larger disc (left-sided) opened safely and freely below the MV apparatus. Once the left ventricular side disc opposed the ventricular surface of AML, the waist and left atrial disc gently released. The patient discharged in the next day. After 6 months, the patient had no more SOB, he returned to his daily activity. Follow-up TTE showed no MR, the closure device was stable in place. Discussion We added a successful case of transcatheter AML perforation to the literature. The role of TOE is crucial in diagnosis and procedure guidance. [ABSTRACT FROM AUTHOR]

Background: Despite being rare, infective endocarditis (IE) is a life-threatening disease with poor prognosis. New diagnostic and therapeutic strategies are emerging; however, predisposing factors and microbiology of the disease are also changing with time. Because of this, there has been a lack of reduction in the disease's incidence and new challenges for clinicians have arisen such as an increasingly aging population and growing antimicrobial resistance.Aims: In this paper, we aim to provide an overview of the changing trends in IE, current diagnosis, and management strategies, as well as the emerging role of the infective endocarditis teams in the care of patients with this disease.Materials& Methods: A comprehensive electronic search was done utilizing PubMed, Ovid, SCOPUS, Embase and google scholar. The search terms included 'Endocarditis', 'IE', 'Infection', 'Vegetation', 'Duke criteria', 'native valve infection', 'prosthetic valve', 'valve infection', 'endocarditis outcome' and 'endocarditis bacteriology'. The references of the identified articles were then searched for any potential articles that can be included. The inclusion criteria were any article that discussed the evidence behind incidence and management of IE including the role of endocarditis team. The exclusion criteria were case reports, expert opinion, and editorials.Results: All the relevant findings are summarized in specified tables and within appropriate sections.Discussion: It is vital to determine the current trends in the epidemiology and microbiology of the condition so that the diagnostic threshold can be adapted, to identify new at-risk groups and achieve an accelerated evaluation strategy that allows for earlier diagnosis and treatment.Conclusion: Management of IE can benefit from the input of different specialties, such as cardiology, cardiothoracic surgery, infectious disease, and microbiology. Therefore, adopting a multidisciplinary approach towards treatment is crucial to reduce morbidity and mortality from preventable complications of this pathology. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) represents one of the most challenging clinical entities, requiring a multidisciplinary approach. The increasing number of surgical and transcatheter heart valves replacements performed annually lead to a higher incidence of prosthetic valve endocarditis. Transcatheter aortic valve implantation (TAVI) brought a new alternative for the treatment of aortic stenosis and a new subgroup of IE with its features. We aimed to compare the incidence of IE in TAVI and surgical valve replacement (SAVR) to identify risk factors for TAVI-IE, evaluate the possible impact on mortality, and clarify the best treatment strategies. A digital scan in PubMed and SCOPUS databases was performed. 68 publications were selected to perform a meta-analysis and systematic review on epidemiology, risk factors, and mortality predictors in TAVI-IE. No significant difference in IE rate was noted between patients with TAVI and those with SAVR for in-hospital, early, mid-term and late IE. Male gender, intubation, new pacemaker implantation IE and CKD were correlated with TAVI-IE. Surgical treatment was performed in 22.3% of cases. Overall mortality for the pooled cohort was 38.3%. In a multivariate logistic regression model, surgical treatment and self-expandable device were linked to lower mortality in TAVI-IE. Even if the invasive procedure can trigger bacteremia, exposing the TAVI valve to future infection, no significant difference in IE rate was noted in our analysis between patients with TAVI and those with SAVR for in-hospital, early, mid-term and late IE. Surgical treatment of TAVI-IE can be a viable option in patients with a prohibitive risk score. [ABSTRACT FROM AUTHOR]

Objective. Infective endocarditis (IE) is a potentially short-term lethal condition. An association with malignancy could complicate diagnostic and therapeutic decisions. The questions to be answered are: (1) which type of malignancies are encountered; (2) how often has the association between malignancy and IE been described, and (3) what are thus far the diagnostic and treatment strategies for patients with both conditions. Methods. A literature search from 2010 to 2018 has been performed with the focus on IE and cancer/malignancy/neoplasm, as well as with risk factors for adverse outcome, when cancer was included in the analysis. Results. An association between digestive, respiratory and hematologic malignancy with IE has been observed in four large databases. The most important mechanisms for this association are a "port of entry" and immune suppression. Sixteen studies dealt with the effect of short and mid-term cancer on the outcome of surgery of IE in these patients. No uniform management strategy could be identified. It seems that a malignancy does not alter the short-term outcome for IE, although referral to a tertiary cardiac center and surgical treatment are less common for patients with known malignancy. Conclusions. Although there is an association between malignancy and IE, no treatment strategy has yet been developed for these patients. Short-term outcome of IE is unaltered by cancer. In most papers, the effect of cancer on mid-term survival is only significant in a univariate analysis, without being a predictor. The results indicate that cardiac surgery for IE should not be withheld in patients in whom a treatable malignancy has been found. [ABSTRACT FROM AUTHOR]

Background Several studies have reported a high risk of ischemic stroke (IS) during the acute phase of infective endocarditis (IE). The long-term risk of IS after IE, however, is not fully illuminated. Methods This Danish, nationwide, register-based, propensity score–matched cohort study used Cox regression to estimate hazard ratios (HRs) of IS for persons with vs without a history of left-sided IE, from 1977 to 2015. Results We followed 9312 patients exposed to a first-time IE and 91 996 nonexposed, matched control persons. Compared to persons without IE, patients with a history of IE had a significantly increased risk of IS; the risk was highest during the first 4 weeks after IE diagnosis (HR 57.20, 95% confidence interval [CI] 45.58–71.78; P <.0001) and a moderately elevated risk persisted until 2 years after IE (4 weeks to 3 months after IE, HR 5.40, 95% CI 4.11–7.19; 3 months to 2 years after IE, HR 1.73, 95% CI 1.48–2.01). Mediation analyses showed that the higher risk of IS the first 2 years after IE could not be explained by atrial fibrillation (AF) or inserted mechanical valves in IE patients. In the period from 4 weeks to 3 months after IE diagnosis, patients treated with anticoagulative therapy had a lower risk of IS (HR 0.30, 95% CI.10–0.96; P =.04). Conclusions Patients with a history of IE had an increased risk of IS for up to 2 years after IE diagnosis. The increased risk was unrelated to AF and inserted mechanical valves. During the initial phase after IE, patients taking an anticoagulative medication had a lower risk of IS. [ABSTRACT FROM AUTHOR]

Infectious diseases (ID) physicians are increasingly responsible for the management of infectious consequences of substance use disorders (SUD). While we are often consulted for diagnosis and treatment of the infectious disease, it is clear that successful management of these infections requires a holistic approach, including acknowledgement and treatment of the underlying SUD. As we have learned through years of treating human immunodeficiency virus and hepatitis C virus infections, ID physicians have unique expertise in addressing both the infection and the complex biopsychosocial factors that underpin the infection. Many ID physicians have incorporated the management of addiction as part of their scope of practice, and here we seek to give a name and define the role of these ID/addiction dual specialists. We define the potential role of ID/addiction physicians in clinical care, health administration, and research, as well as provide recommendations to bolster the supply and reach of this burgeoning subspecialty. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) is a life threatening disease requiring lengthy hospitalizations, complex multidisciplinary management and high health care costs. In this study, we analyzed the National Readmissions' Database (NRD) to identify infective endocarditis cases and the causative organisms, clinical determinants, length of stay, in-hospital mortality, and 30-day hospital readmission rates. The study cohort was derived from Healthcare Cost and Utilization Project's National Readmission Database between 2010-15. We queried the National Readmissions' Database using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic code for infective endocarditis (421.0) and identified a total of 187,438 index admissions. SAS 9.4 (SAS Institute Inc., Cary, NC) was utilized for statistical analyses. A total of 187,438 patients with a primary diagnosis of IE were identified over 6 years (2010-2015). Twenty-four percent (44,151 patients) were readmitted within 30 days. Most common etiologies for readmission included sepsis (14%), acute heart failure (8%), acute kidney injury (6%), intracardiac device infection (5.6%) and recurrence of IE (2.7%). Predictors of increased readmissions included female sex, staphylococcus aureus infection, diabetes, chronic lung disease, chronic liver disease, acute kidney injury, acute heart failure and anemia. In-hospital mortality for the readmission of IE was 13%, and average length of stay during the re-admission was 12 days. IE is associated with high rates of index admission mortality and for 30-day readmissions of which are associated with a substantial risk of death. [ABSTRACT FROM AUTHOR]

Despite the fact that more and more guidelines that systematize our knowledge are being published, infective endocarditis remains a considerable diagnostic and therapeutic challenge. This is partially caused by the variable course of the disease process and numerous potential complications with high mortality. We present a case of a 48-year-old police officer with an inflammatory process within the aortic valve that led to the development of peripheral emboli in the central nervous system, kidney, spleen and within the lumbosacral spine. The complexity of the clinical situation required the cooperation of various medical specialists and combined use of various imaging methods, including ultrasound. This ultimately enabled the correct diagnosis to be established and had a significant impact on the planning and monitoring of the diagnostic process. [ABSTRACT FROM AUTHOR]

Infectious endocarditis is a highly morbid disease with approximately 43,000 cases per year in the United States. The modified Duke Criteria have poor sensitivity; however, advances in diagnostic imaging provide new tools for clinicians to make what can be an elusive diagnosis. There are a number of risk stratification calculators that can help guide providers in medical and surgical management. Patients who inject drugs pose unique challenges for the health care system as their addiction, which is often untreated, can lead to recurrent infections after valve replacement. There is a need to increase access to medication-assisted treatment for opioid use disorders in this population. Recent studies suggest that oral and depo antibiotics may be viable alternatives to conventional intravenous therapy. Additionally, shorter courses of antibiotic therapy are potentially equally efficacious in patients who are surgically managed. Given the complexities involved with their care, patients with endocarditis are best managed by multidisciplinary teams. [ABSTRACT FROM AUTHOR]

Ceftobiprole is a broad-spectrum, fifth-generation cephalosporin currently approved for community-acquired and non-ventilator-associated hospital-acquired pneumonia. High bactericidal and anti-biofilm activity has been exhibited in in vitro and animal models. This, together with its synergism with other antibiotics against gram-positive bacteria, makes it an ideal candidate for treatment of complex infections, such as those associated with devices or infective endocarditis. More clinical data are needed to achieve drug positioning. [ABSTRACT FROM AUTHOR]

Dalbavancin is a long-acting antimicrobial agent with an excellent in vitro activity against Gram-positive pathogens, including staphylococcal biofilms. The unusually long terminal half-life ranging from 149 to 250 hours in human subjects, allows a weekly dose. Currently is indicated in acute bacterial skin and skin structure infections (ABSSSIs), but in real-life clinical practice it has already been used successfully and safely in other infections, especially as consolidation therapy. [ABSTRACT FROM AUTHOR]

Background In the management of infective endocarditis (IE), the presence of extracardiac complications has an influence on both diagnosis and treatment. Current guidelines suggest that systematic thoracoabdominal-pelvic computed tomography (TAP-CT) may be helpful. Our objective was to describe how systematic TAP-CT affects the diagnosis and the management of IE. Methods In this multicenter cohort study, between January 2013 and July 2016 we included consecutive patients who had definite or possible IE according to the Duke modified criteria, validated by endocarditis teams. We analyzed whether the Duke classification and therapeutic management were modified regarding the presence or the absence of IE-related lesion on CT and investigated the tolerance of this examination. Results Of the 522 patients included in this study, 217 (41.6%) had 1 or more IE-related lesions. On the basis of CT results in asymptomatic patients, diagnostic classification was upgraded from possible endocarditis to definite endocarditis for only 4 cases (0.8%). The presence of IE-related lesions on CT did not modify the duration of antibiotic treatment (P =.55), nor the decision of surgical treatment (P =.39). Specific treatment of the lesion was necessary in 42 patients (8.0%), but only 9 of these lesions (1.9%) were asymptomatic and diagnosed only on the TAP-CT. Acute kidney injury (AKI) within 5 days of CT was observed in 78 patients (14.9%). Conclusions The TAP-CT findings slightly affected diagnosis and treatment of IE in a very small proportion of asymptomatic patients. Furthermore, contrast media should be used with caution because of the high risk of AKI. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) is a potentially life-threatening disease which carries high risk of morbidity and mortality. The variability of clinical presentation of infective IE remains a diagnostic challenge for the Emergency Physicians. The clinical manifestation may present as an acute, rapidly progressive infection with the absence of classical immunological vascular phenomenon or as subacute or chronic disease with vague constitutional symptoms that may mislead initial assessment and mimic other conditions. Symptoms may also manifest as a result of systemic embolization which can be catastrophic and life-threatening especially if it ends up in the cerebral circulation. IE complicated by cerebral mycotic aneurysm (CMA) is the worst neurological sequalae and can be misdiagnosed as a primary intracranial infection such as meningoencephalitis. Here, we report a case of neurological emergency secondary to systemic embolization of IE with a devastating diagnosis of CMA. History of prolonged fever associated with headache and focal neurological deficit led to the initial diagnosis of meningoencephalitis due to a low clinical suspicion of the disease in the Emergency Department. In emergency setting, a combination of high degree of clinical suspicion together with thorough history, physical examination and diagnostic imaging are crucial in order to guide and establish the diagnosis of this potentially devastating disease. Early recognition and initiation of aggressive treatment is crucial to provide better prognosis and higher survival rate for patients with CMA. [ABSTRACT FROM AUTHOR]

People who inject drugs (PWID) represent a high-risk subgroup of endocarditis patients. This is highlighted by poorer post-operative outcomes in injection drug use-related infective endocarditis (IDU-IE), which is largely attributable to the increased vulnerability of prosthetic valves to re-infection. Consequently, many centres do not perform valve replacement on these patients. A parallel, but often underrecognized, component of care is the role of multidisciplinary management for individuals with IDU-IE, including perioperative addictions and psychiatric care. Consequently, surgical management options in IDU-IE remain a controversial topic. To determine the characteristics of optimal surgical and psychiatric care for individuals with IDU-IE. We conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, organizing the findings into several key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions. Managing IDU-IE involves the treatment of two comorbidities: the intra-cardiac infection and the underlying substance use disorder. Cardiac surgery represents a high-intensity intervention with appreciable risk, and the benefit it is not always clear. As patients often present acutely, it is not feasible to use drug abstinence as a prerequisite to surgery. Involvement of inpatient psychiatry and addictions teams, however, appears to be an evidence-based approach that can bridge IDU-IE patients with opioid agonist therapy in hospital and adequate outpatient treatment options for their underlying addiction upon their discharge from hospital. It is likely that a majority of these patients are not receiving optimal psychiatric management despite increasing recognition of efficacy. Further interdisciplinary studies are needed to elucidate optimal surgical and multidisciplinary protocols. Infective endocarditis (IE) is an infection of the innermost lining of the heart often affecting the heart valves. Over the last few decades, the epidemiology of IE has shifted in the developed world and while it continues to be a significant cause of morbidity and mortality, there has been a significant increased incidence among persons who inject drugs (PWID). To date, well-conducted epidemiologic studies of IE among PWID have been sparse, which has limited our ability to fully characterize this disease phenomenon. To address this knowledge deficit, we conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, and organized our findings into six key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) is an uncommon, life-threatening systemic disorder with significant morbidity and persistently high mortality. The age of the peak incidence of IE has shifted from 45 years in the 1950s to 70 years at the present time, and elderly people have a five-fold higher risk of IE than the general adult population. Elderly IE patients demonstrate a higher prevalence of coagulase-negative staphylococci, enterococci and Streptococcus bovis, and lower rates of infection by viridans group streptococci. Methicillin resistance is more prevalent in elderly patients as a consequence of increased nosocomial acquisition. The elderly are a vulnerable group in whom diagnosis is often difficult on account of non-specific presenting features and where higher prevalence of comorbidities contributes to adverse outcomes. Treatment of older patients with IE presents specific challenges associated with prolonged antibiotic therapy, and access to surgery may be denied on account of advanced age and attendant comorbidities. This practical review covers all aspects of elderly IE, including clinical and microbiological diagnosis and appropriate diagnostic procedures, initial antibiotic selection, antibiotic prophylaxis, considerations about antibiotic therapy and surgery. [ABSTRACT FROM AUTHOR]

Objectives: Enterococcal bacteremia can be complicated by infective endocarditis (IE) and when suspected, transesophageal echocardiography (TEE) should be performed. The previously published NOVA score can identify patients with enterococcal bacteremia at risk for IE and we aimed to improve the score.Methods: Factors associated with IE were studied retrospectively in a population-based cohort of patients with monomicrobial Enterococcus faecalis bacteremia (MEFsB). Factors associated with IE in multivariable analysis were included in a new score system which was compared to the NOVA score and validated in a cohort of patients with MEFsB from another region.Results: Among 397 episodes of MEFsB, 44 episodes with IE were compared to those without IE. Long Duration of symptoms (≥ 7 days) and Embolization were associated with IE in the multivariate analysis and hence were added to the NOVA variables (Number of positive cultures, Origin of infection unknown, Valve disease, and Auscultation of murmur) to generate a novel score; DENOVA. The area under the curve in ROC analyses was higher for DENOVA (0.95) compared to NOVA (0.91) (p = 0.001). With a cutoff at ≥ 3 positive variables the DENOVA score has a sensitivity of 100% and specificity of 83% which is superior to the NOVA score (specificity 29%). The DENOVA score was applied to the validation cohort (26 IE episodes and 256 non-IE episodes) and the resulting sensitivity was 100% and the specificity was 85% compared to 35% for NOVA.Conclusions: The DENOVA score is a useful tool to identify patients with MEFsB where TEE is not needed. [ABSTRACT FROM AUTHOR]