Search

While trained infectious diseases (ID) specialists are regularly involved in inpatient and outpatient care in the United States and Canada, these specialized services are only rarely established in Germany. This article aims to summarize the findings of numerous studies that investigated the impact of ID consultation services on patient care and outcome in patients suffering from infectious diseases. The strongest evidence for a clinical benefit is found in the context of Staphylococcus aureus bacteremia (SAB), where in-hospital- and day-30 mortality was significantly and consistently reduced by about 40% in patients that were evaluated and treated in cooperation with an ID physician. Furthermore, studies revealed that this effect was associated with an improved adherence to standards of care. Newer studies show a reduced length of hospital stay due to ID consultations, especially if patients are evaluated early in the course of their hospital stay. Of note, informal or curbside consultations do not seem to be equivalent to a formal ID consultation with bedside patient evaluation. Studies in other patient groups (solid organ transplant recipients or intensive care unit patients) or in the context of other infections (infective endocarditis, pneumonia, other bloodstream infections) also revealed positive effects of ID consultations. Higher rates of appropriate empirical and targeted antimicrobial treatments and de-escalation strategies due to successful pathogen identification were documented. These modifications resulted in lower treatment costs and decreased antimicrobial resistance development. Although there are methodological limitations in single studies, we consider the consistent and reproducible positive effects of ID consultations shown in studies in different countries and health care systems as convincing evidence for the improved quality of care and treatment outcomes in patients with infectious diseases. Thus, strong consideration should be given to establish ID consultation services in small and medium sized hospitals as well., (Copyright © 2015. Published by Elsevier GmbH.)

Infectious endocarditis is a rare disease with high mortality. Epidemiological changes in recent years, the emergence of new risk factors, and the increasing use of intravasal prosthetic materials has led to changes in not only the clinical appearance of this disease but also in its diagnosis and treatment. Early diagnosis of infectious endocarditis is crucial. However, the often unspecific symptoms and the changes in its epidemiologic profile pose a challenge for the treating physician. This is especially true since the incidence of hospital-acquired, "nosocomial" cases of infectious endocarditis is increasing and often affects severely ill patients in intensive care units (ICU). There are diagnostic and therapeutic algorithms to guide the physician from an early diagnosis to an adequate treatment of the disease. In some critically ill patients, only surgery in combination with antimicrobial treatment may lead to complete eradication of the infectious disease. This review aims to subsume the guidelines, paying special attention to aspects that are important for intensive care and emergency doctors.

Infective endocarditis is an infection of cardiovascular structures which is typically caused by bacteria. Despite recent medical advances mortality reaches up to 26% which is even higher with mortality rates of up to 84% in complex cases leading to admission to intensive care units. The diagnosis is based on positive blood culture results with identical microorganisms and the demonstration of endocardial involvement. A rapid initiation of an adequate therapeutic regimen is important to prevent the patients from severe complications such as heart failure, uncontrolled infection or septic embolism. An early and targeted initiation of an antibiotic therapy after microbiologic testing is crucial for therapeutic success. The immediate cooperation of Cardiologists, Microbiologists, Infectious Disease Specialists and Cardiac Surgeons is highly recommended to allow an adequate medical and surgical treatment without delay in complex cases. Antibiotic treatment has to be continued postoperatively.

The study objective was to evaluate the long-term influence of non-radical surgical and restorative dental treatment modalities prior to elective cardiac valve replacement on the subsequent dental treatment demand. A total of 305 patients preceding cardiac valve surgery were screened and the appropriate dental treatment was initiated. After 36 months 80 patients were re-evaluated clinically, of which 60 required dental restorations of 155 teeth, mostly due to periodontal pathology. Independent of the sub-group there was a statistically substantial increase of the treatment demand compared to the time of initial examination. In addition, at the time of final re-evaluation the definite treatment need significantly increased far beyond anticipation, potentially due to inadequate dental procedures during the follow-up interval. Irrespective of any dental treatment or antibiotic application, endocarditis did not occur in any patient. Non-radical dental restoration prior to cardiac valve replacement can only be successful, if a standardized dental follow-up with common monitoring forms is provided. The risk of prosthetic valve infective endocarditis based on a dental focus is probably overestimated.

Microbe-induced (infectious) endocarditis is an endovascular infection, caused mainly by bacteria, of cardiovascular structures. The major predilection site are the native heart valves, but involvement of implanted intracardiac foreign material is increasingly being seen. The mortality rate of infectious endocarditis depends on clinical factors and the causal agent, but also on the time of the establishment of the diagnosis and the initiation of appropriate treatment. In Germany, the current mortality rate ranges up to 18%. Between January 2003 and July 2004, with the aim of improving patient care and thus the outcome of this condition, a guideline commission worked out recommendations for the diagnosis, treatment and management of the disease for the use of general practitioners and hospital physicians, in particular microbiologists, infectiologists, cardiologists and cardiac surgeons. The basis for this guideline was the systematic search through the literature of the European guideline. On the 16th and 28th of June 2004, the entire guideline was formerly approved in a nominal group process.

Background: The Sorin Pericarbon Freedom Stentless aortic valve has the potential to provide superior hemodynamic function and durability. In this study we assessed the hemodynamic performance of this valve and its impact on LV-mass regression after aortic valve replacement., Methods: 31 consecutive patients who received a Sorin Pericarbon Freedom Stentless aortic valve were analysed. Mean age of the patients (16 female and 15 male) was 64 +/- 17 years. Five patients had isolated aortic stenosis, three isolated aortic regurgitation and one combined aortic valve disease. Three patients had combined aortic and mitral valve disease, 14 patients concomitant coronary artery disease, one congenital aortic coarctation. Three patients had an acute aortic valve endocarditis. 18 patients were classified as high-risk patients (mean EuroSCORE 9 +/- 2). Mean left ventricular ejection fraction was 52.5 +/- 15.0%., Results: Valve sizes from 21 mm to 29 mm were implanted. The valves were oversized by 2 mm compared to measurement. 16 patients received isolated aortic valve replacement, Three patients aortic valve replacement and mitral valve reconstruction. 12 patients had concomitant CABG. Three procedures were reoperations. Hospital mortality was 6.4% (two patients). Both deaths occurred in high-risk patients and were not valve-related. Four patients had perioperative low-output-syndrome and needed IABP. After six months a follow up echocardiography was performed. Mean and peak gradients were 9.6 +/- 4.4 and 20.6 +/- 5.9 mmHg, respectively. Significant reduction of left ventricular hypertrophy (LV mass index 126.5 +/- 27.3 vs. 189.6 +/- 45.3 g/m2, p = 0.0313) and improvement of the ejection fraction (58 +/- 9.8 vs. 52.5 +/- 15.0%, p = 0.9749) as compared with preoperative valve., Conclusions: The hemodynamic performance of the Sorin Pericarbon Freedom Stentless aortic valve is excellent and the patient outcome is satisfying. However the implantation technique requires longer ischemic time, the prosthesis offers very satisfying hemodynamic function and accelerates probably the LV-mass regression in the mid term follow-up. Late performance and durability of the valve have to be assessed.

Operative treatment of acute valve endocarditis with paravalvular abscess remains a surgical challenge. The aim of the study was gaining insights into the influence of our surgical strategy on the short- and midterm results. Over a period of 7 years 18 patients underwent surgical treatment of a paravalvular abscess accompanying their acute aortic valve endocarditis. All patients ranged preoperative in the NYHA class IV. Eleven patients suffered from native and 7 from prosthetic aortic valve endocarditis. Staphylococcus aureus was found to have caused the infection in 50% of the cases. Surgical therapy consisted in all patients of thorough resection of the infected tissue followed by reconstruction of the defect with the aid of autologus pericardial patch and replacement of the aortic valve using a prosthesis. Although the rate of complications continued high early lethality remained at 5.5%. Midterm results proved to be very good with a follow-up of 44 month. Both lethality and the reoperation rate stayed at 0%. The operative risk of acute aortic valve endocarditis with paravalvular abscess is high but acceptable. Should a paravalvular abscess be diagnosed during a case of endocarditis urgent surgical therapy is highly advisable even there is only a minor deterioration of the patient' clinical state. Radical abscess debridement in combination with exclusion of the place of resection from circulation using an autologus pericard patch is a necessary condition for achieving good results.

Late results after surgery for acute infectious aortic endocarditis using allografts are compared with those achieved with bioprostheses or mechanical heart valves. Cryopreserved allografts were used in 74 (22%) and prosthetic heart valve in 262 out of 336 (78%) patients presenting acute aortic endocarditis. Prosthetic (p = 0.001) and destructive endocarditis (p = 0.001) were more frequent in patients receiving allografts. Mean follow-up time was 6.6 +/- 4 years (range, 3 to 28 years). The 30-day-mortality was 19% for allograft patients and 6% for those receiving prosthetic heart valves (p = 0.002). Early reoperation, postoperative renal failure and sepsis did not differ between groups. After 20 years, actuarial survival was 60% for mechanical heart valves, 44% for bioprosthesis and 38% for allografts (p = 0.003), reoperation was unnecessary in 52% of mechanical heart valves and 10% of bioprostheses and allografts (p = 0.0007). Acute infection at the time of operation (p = 0.0001), redo surgery (p = 0.0006), staphylococci (p = 0.0003), older age (p = 0.004) and mitral valve involvement (p = 0.004) were risk factors for late death, irrespective of preoperative antibiotic treatment and type of prosthesis used. A longer bypass and aortic cross-clamp time predicted early (p = 0.0001) and late survival (p = 0.0001), independently. Destructive aortic endocarditis has a poor long-term outcome irrespective of the use of allografts. Acute infection at the time of surgery predicted early and late death; however, surgery is indicated prior to secondary involvement of the mitral valve. The duration of preoperative antibiotic treatment did not affect outcome. A thorough surgical technique directly influences early and late survival.

The occurrence of paravalvular abscesses in the course of an acute endocarditis of the aortic valve indicates an advanced stadium of the disease. The infection has spread beyond the limits of the valve leaflets, and ongoing destruction of the paravalvular tissue is to be expected, if the endocarditis is continually treated by antibiotics alone. Surgery of acute endocarditis with paravalvular abscess, however, supposedly carries an increased risk of early mortality and late morbidity. The following prospective study was carried out to determine whether a radical surgical approach together with aggressive postoperative antibiotic therapy could help to improve results. Between 1988 and 1995, 138 patients were operated during the acute phase of infective endocarditis; in 102 the aortic valve was involved. Among these, 44 had paravalvular abscesses at the time of surgery. The mean age of both groups was the same, but there was a higher rate of concomitant coronary artery disease, multiple valve involvement, advanced NYHA-class, and staphylococcal disease among the patients with abscesses. All interventions were carried out with cardiopulmonary bypass and cardioplegic arrest. The aortic valve was resected, abscesses were removed, and each part of potentially infected or necrotic tissue was resected as complete as possible, irrespective of the possibility to jeopardize the conduction system or to create large tissue defects. The aortic valve was replaced with a mechanical prosthesis in each case. The postoperative antibiotic regimen was specifically directed against the microorganisms isolated preoperatively; therapy was only modified, if signs of systemic infection did not disappear three days after surgery. The operative mortality was 10% among patients without an abscess and 11% in patients with a paravalvular abscess. Early recurrent endocarditis was recorded in two patients without and in only one patient with an abscess. Late recurrent endocarditis was noted in three patients; none of them had abscesses at the time of surgery. We conclude that the operative risk of acute endocarditis of the aortic valve with a paravalvular abscess does not have to be inevitably higher compared to cases without paravalvular involvement. To achieve these results, it is necessary to use a radical surgical approach and to adjust postoperative antibiotic therapy, if infectious signs do not disappear shortly after surgery.

Embolic complications are a major prognostic determinant in the clinical course of infective endocarditis (IE) with an incidence of about 30-50%. In order to analyze risk factors leading to embolism in native (NVE) and prosthetic valve endocarditis (PVE), we reviewed 177 consecutive patients; 43% were female, 57% male, PVE occurred in 24% of all patients all left-sided, among the NVE were 11% right-sided IE. Major embolic complications occurred in 40% of all patients. In NVE, a higher rate of embolic events (45% vs. 26%; p < 0.05), and a larger vegetation size compared to PVE was observed (14 +/- 6 mm vs. 11 +/- 5 mm; p < 0.05). The most important risk factor for embolic complications in NVE was Staphylococcus aureus (odds ratio 6.4). Furthermore, double valve endocarditis, fever, and mitral valve endocarditis were associated with the risk for embolism. In case of severe regurgitation the rate of embolic complications was reduced (54% vs. 77%; p < 0.05). In PVE, fever was a risk factor for embolic events. Staphylococcus aureus was also a frequent microorganism in embolism (45% vs. 22%). The in-hospital mortality was significantly increased in case of embolism (NVE 40% vs. 11%; p < 0.001; PVE 36% vs. 9% p < 0.05). About 50% of all embolic events occurred before admission. In NVE, due to high in-hospital mortality, the rate of patients with embolism undergoing surgery was lower (57% vs. 72%; p < 0.05); whereas in PVE no significant difference was observed. In patients with NVE, aspirin therapy because of coronary artery disease appeared to reduce the rate of embolic complications (11% vs. 47%). However, the low number of patients on aspirin (9%) does not allow recommendations regarding a potential benefit. In conclusion, identification of risk factors leading to embolism in IE may be useful in considering early surgical therapy. However, the high rate of embolic complications before hospital admission indicates a need for improving the diagnostic delay in the prehospital phase.

The clinical features of 5 patients with invasive disease due to nontoxigenic Corynebacterium diphtheriae are presented. 4 patients had proven left sided endocarditis, and one had probable endocarditis of the mitral valve. 4 patients were intravenous drug abusers, and one had a girl friend who was also an iv-drug abuser. Only one patient had antibodies against human immunodeficiency virus. 2 patients with endocarditis of the mitral or the aortic valve, and one patient with endocarditis of a prosthetic aortic valve, died of septic complications. All patients or their partners frequented the same community of drug abusers. Since the blood culture isolates shared common features for biotyping, resistance patterns and also for ribotyping in three tested patients, we assume that all patients were infected by the same clone of C. diphtheriae. Drug abusers may become a new reservoir for C. diphtheriae infection. Along with our patients, we present an overview of the 49 published cases of C. diphtheriae endocarditis.

The following retrospective study analyzes 51 patients aged 45.8 +/- 11 years with infective endocarditis diagnosed from January 1, 1980-December 31, 1989. The aortic valve was mainly affected (59%). 92% of patients showed predisposing factors or a directly related incident. Positive blood cultures were found in 63% of patients. The dominating bacterium was streptococcus viridans (31%) with decreasing tendency compared to the previous decade, followed by staphylococcus aureus (22%) with significantly increasing tendency. Clinical and laboratory findings were not different from those of the previous decade. Main complications in the early period of disease turned out to be acute heart failure (69%) and arterial embolism (41%) which was dependent on the severity of disease. Mortality within the initial 6 months was significantly lower than in the previous decade (16% vs 31%). Patients undergoing heart-valve replacement within the first 6 months of disease (59%) had a mortality rate of 10%, which was significantly smaller than the 24% mortality rate of patients not being operated during the same period. Furthermore, patients with staphylococcus aureus endocarditis demonstrated a markedly worse early prognosis (6 month survival rate 28.6 +/- 17.2% vs 80.0 +/- 6.1% in patients with infective endocarditis other than staphylococcus aureus-related). Late mortality was not different in the above-mentioned subgroups with a 5-year survival of more than 80%. However, surgically treated patients significantly improved their functional class in the follow-up period over medically treated patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence of infective endocarditis in drug addicts is increasing with the spreading of intravenous drug abuse. The tricuspid valve is the most commonly involved valve followed by the mitral valve. We evaluated prospectively 22 patients with a mean age of 23 years, presenting with addiction-associated endocarditis endocarditis and referred to our institution during a three-year period. The tricuspid valve was involved in 13 instances, mitral valve in 4, mitral plus tricuspid valve in 5 patients and aortic valve in 1 case. Staphylococcus aureus was the most frequent infective organism (15x), followed by Streptococci (4x), Corynebacteria (2x) and one case with a mixed infection. Six patients were positive for an HIV-infection and 17 had evidence for a chronic viral hepatitis. Ten patients (3 of them HIV-seropositive) were treated surgically. Resection of the tricuspid valve with (1x) or without replacement (4x), resection of vegetations and valve repair (2x), mitral valve replacement (2x), aortic valve replacement (1x) were performed. In case of tricuspid endocarditis, the decision whether to proceed with resection, repair or replacement with a bioprosthesis was taken according to valve pathology and the psycho-social situation of the patient. When the vegetations involved only one leaflet and could be removed easily, vegetectomy with annuloplasty or with repair using autologous pericardium was performed. Valvulectomy without replacement was the chosen method for those where persistent or recurrent drug abuse could not be excluded. A bioprosthesis was inserted when the tricuspid valve was completely destroyed and there was a proven abstinence from drugs over a period of several weeks preoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1/1986 and 5/1992 a total of 5283 surgical procedures involving extracorporal circulation were performed at our clinic, including 44 patients who underwent a total of 54 operations for acute endocarditis. On the basis of a retrospective study, this paper presents the pre-operative findings and the results of surgery in relation to the duration of the case history. Pathogenic microorganisms were successfully grown from the blood cultures of 63.6% (n = 31) of the patients. Among these microorganisms were viridans streptococci (n = 12), coagulase-negative staphylococci (n = 5), staph. aureus (n = 5), beta-haemolytic streptococci (n = 2) as well as combined infections (n = 2) and miscellanea. Preoperatively, 38 patients were in NYHA stage III or IV. Surgery resulted in an average improvement of 1.6 NYHA classes from NYHA 3.3 to NYHA 1.7. The total-mortality rate was n = 13; early mortality was n = 3. The mean follow-up period was 3.9 years (minimum 5 weeks, maximum 6.4 years). The time elapsed between initial clinical manifestation of the disease and operation had a significant influence on mortality and on the prevalence of complications. Patients who died of endocarditis had a significantly longer case history (p < 0.05). The prognosis was poorer, according to our data, if the case history extended over more than 80 days. Our results demonstrate clearly the necessity for such patients to be referred to a heart surgeon without delay.

Prophylactic antibiotic coverage of all interventions with a high risk of bacteremia is accepted practice in patients with valvular heart disease. A true cost-benefit ratio, however, has not been possible to demonstrate due to the low risk involved in these procedures, and therefore the current recommendations rely on experimental work with laboratory animals. Full application of these findings in patients is difficult and even so incapable of preventing the majority of cases of infective endocarditis.

Bacterial endocarditis was the cause of heart valve destruction in 23 patients. Additional 5 patients were reoperated because of an infected valve prothesis. 13 were operated upon during the inactive stage. Nevertheless infection recurred after operation at least in one patient. 10 patients underwent operation during the active stage, 6 of these with stable cardiac function, 4 in cardiogenic shock. Hospital mortality was 2/6 and 1/4 respectively. One patient died after three months of persisting infection. Three of five patients with infected valve prosthesis survived reoperation. An attempt is made to define the indication for valve surgery in bacterial endocarditis.

In 40 patients with acute bacterial endocarditis, the indication for cardiac valve replacement was established exclusively on the basis of the echocardiographic and clinical findings. The patients had an average age of 42 years and were under followup observation for an average of 2.2 years. The endocarditis involved the aortic valve 32 times, the mitral valve once, the tricuspid valve in two cases and the aortic and mitral valve together in five cases. In addition to the valve replacement, a ventricular septum defect and aneurysm of the ascending aorta had to be dealt with surgically in two cases each. The intraoperative and perioperative lethality was 2.5% (n = 1). The postoperative lethality was 12.5% (n = 5). In the surviving 34 patients, a recurrence of the endocarditis has not occurred up to now in any case. According to the NYHA classification, six of the surviving patients were to be classified as stage II and 28 as stage I, whereas stage III or IV had been present preoperatively in all cases. The postoperative echocardiographic investigation revealed a significant decrease of the left ventricular enddiastolic diameter (from 61 +/- 8 mm to 51 +/- 5 mm; P less than 0.001). In four cases, a slight insufficiency of the artificial valve could be detected. Reoperation was not necessary in any of these patients.

The prognosis of valvular heart disease is favorably influenced by surgical treatment in spite of the possible incurrence of early or late postoperative complications. The hemodynamic properties of currently implanted bioprostheses and mechanical prostheses are essentially similar. It can be assumed that the fate of the patient, after having survived the early-postoperative phase, is predominantly dependent on the underlying disease and on complications of the prosthetic valve, itself, or the inherent necessity for chronic anticoagulation. To characterize the longterm course more closely, in this study in patients with prosthetic aortic or mitral valves, analysis of the survival rate as well as incidence of valvular dysfunction, late endocarditis, thromboembolism and bleeding associated with anticoagulant therapy was performed separately for patients with Björk-Shiley prostheses and for those with bioprostheses. The study encompasses 407 patients after isolated aortic valve replacement, 226 with Björk-Shiley prosthesis and 181 with bioprosthesis, as well as 269 patients after isolated mitral valve replacement, 142 with Björk-Shiley prosthesis and 127 with bioprosthesis (Table 2). All patients had valve replacement between 1975 and 1983 which was performed in the Department of Cardiovascular Surgery at the German Heart Center in Munich under comparable conditions, since 1977 with employment of cardioplegia. The preoperative characteristics of the groups compared did not differ significantly from each other (Table 1). Continuous follow-up was obtained in 95% of the patients. The mean observation period of all four compared patient groups ranged between 52.1 and 61.3 months. The term "major complication" was used to designate late-postoperative death, hemodynamic derangement due to prosthetic dysfunction, late endocarditis as well as major thromboembolism or bleeding. Prosthetic dysfunction in the case of Björk-Shiley valves was designated as mechanical or due to thrombosis, in the case of bioprostheses as valve degeneration or thrombosis. Late endocarditis was diagnosed only on documentation of - with a minimum interval of 30 days between valve implantation and onset of symptoms - changes in auscultatory findings and a morphological substrate on the implanted valve. Thromboembolism was assumed, after ruling out bleeding, only if a definitive or highly-probable transient or permanent neurologic deficit or a well-established suspicion of acute ischemia in an extremity or visceral organ was present. A bleeding complication was considered as such only if treatment by a physician was required.(ABSTRACT TRUNCATED AT 400 WORDS)

In a retrospective study of 35,220 autopsies performed from 1950 to 1984 in our department, septicaemia was found in 707 cases (2% of all autopsies). The incidence of pyaemia decreased after 1960, whereas that of septicaemia increased significantly. This increase was observed in surgical and medical departments due to patients suffering from neoplastic disease who died of septicaemia (40% of our cases). In the paediatric departments, however, mortality from septicaemia decreased slowly, but continuously. Age distribution revealed two peaks, one in infancy and one in patients older than 60 years. Over the past decade the mean age increased significantly (15 years on average). In blood cultures gram negative bacteria were found more often than gram positive strains.