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Patients with diabetes mellitus (DM) have a higher incidence of infections, and those with bacteremia are more prone to develop sepsis and infective endocarditis (IE). Nevertheless, data concerning the impact of DM on the prognosis of patients with IE are limited and sometimes contradictory. We examined the impact of DM on the inhospital outcome of left-sided IE in a large cohort of patients. We studied 594 consecutive episodes of left-sided IE diagnosed at 3 tertiary care centers. They were divided into 2 groups: episodes in patients with DM (n = 114) and episodes in patients without DM (n = 480). We retrospectively analyzed the influence of DM therapy on patient outcome. Compared to patients without DM, patients with DM were older (67 ± 10 vs. 60 ± 15 yr; p < 0.001), less frequently male (53.5% vs. 67.9%; p = 0.004), and more commonly had chronic renal failure (23.9% vs. 6.9%; p < 0.001) and chronic obstructive pulmonary disease (14.6% vs. 7.8%; p = 0.019). Enterococcus (14.9% vs. 7.4%; p = 0.011) and Streptococcus bovis (8.8% vs. 3.8%; p = 0.024) were isolated more frequently. In the univariable analysis, septic shock (29.2% vs. 16.4%; p = 0.005) and mortality (43.5% vs. 30.0%; p = 0.008) were more common among patients with DM than in those without. Considering the different treatments for DM, septic shock (33.3%; p = 0.011) and death (50.8%; p = 0.012) were more frequent in patients receiving oral medication to treat diabetes than in patients with the other treatment modalities. However, multivariable analysis showed that DM had an independent association with development of septic shock (OR 2.282; 95% CI 1.186-4.393), but it was not a predictor of inhospital mortality.Staphylococci were the most frequently involved microorganisms in all patients; however, Enterococcus and Streptococcus bovis were more frequently isolated from individuals with DM and left-sided IE, whereas viridans group streptococci were more commonly isolated from those with left-sided IE who did not have DM. DM was independently associated with the development of septic shock, but it was not an independent predictor of inhospital mortality in patients with left-sided IE.

Staphylococcus aureus prosthetic valve endocarditis (SAPVE) has a poor prognosis. There are no large series that accurately describe this entity. This is a retrospective observational study on a prospective cohort from 3 Spanish reference hospitals for cardiac surgery, including 78 definitive episodes of left SAPVE between 1996 and 2016. Fifty percent had a Charlson Index score >5; 53% were health care-related. Twenty percent did not present fever. Complications at diagnosis included: severe heart failure (HF, 29%), septic shock (SS, 17.9%), central nervous system abnormalities (19%), septic metastasis (4%). Hemorrhagic stroke was not higher in anticoagulated patients. Twenty-seven percent were methicilin-resistant SA (MRSA). Fifteen of 31 had positive valve culture; it was related to surgery within first 24 hours. At diagnosis, 69% had vegetation (>10 mm in 75%), 21.8% perianular extension, and 20% prosthetic dehiscence. Forty-eight percent had persistent bacteremia, related to nonsurgical treatment. Perianular extension progressed in 18%. Surgery was performed in 35 episodes (12 with stroke). Eleven uncomplicated episodes were managed with medical therapy, 8 survived. In-hospital mortality was 55%, higher in episodes with hemorrhagic stroke (77.8% vs 52.2%, odds ratio 3.2 [0.62–16.55]). Early SAPVE was nosocomial (92%), presented as severe HF (54%), patients were diagnosed and operated on early, 38% died. In intermediate SAPVE (9 weeks–1 year) diagnosis was delayed (24%), patients presented with constitutional syndrome (18%), renal failure (41%), and underwent surgery >72 hours after indication; 53% died. Late SAPVE (>1 year) was related with health care, diagnosis delay, and 60% of deceases. Left SAPVE frequently affected patients with comorbidity and health care contact. Complications at diagnosis and absence of fever were frequent. Presence of MRSA was high. Positive valve culture was related to early surgery. Paravalvular extension was frequent; vegetations were large, but its absence at diagnosis was common. Some uncomplicated SAPVE episodes were safety treated with medical therapy. Surgery was feasible in patients with stroke. Mortality was high. There were differences in some clinical characteristics and in evolution according to the time elapsed from valve replacement. Prognosis was better in early SAPVE.

Whether infection in more than 1 valve worsens the prognosis for endocarditis remains untested. We conducted the current study to determine the profile of multiple-valve endocarditis, compare multiple-valve endocarditis with single-valve endocarditis, and determine predictors of outcome. We conducted a prospective and observational study including 680 episodes of infective endocarditis consecutively diagnosed at 3 tertiary centers. Multiple valve involvement was present in 115 episodes (17%), and single valve involvement in 530 (78%). In the remaining 35 cases, valvular involvement could not be documented. Mean age of patients with multiple valve endocarditis was 58 years. Clinical complications were frequent (heart failure 65%, renal failure 44%, systemic embolisms 24%). The microorganism most frequently isolated was Staphylococcus aureus (22%).Factors predictive of in-hospital mortality in the univariate analysis were septic shock, prosthetic endocarditis, heart failure, and persistent infection. In the multivariate analysis, we detected heart failure (odds ratios [OR], 4.7; 95% confidence interval [CI], 1.6-13.8) and persistent infection (OR, 4.3; 95% CI, 1.7-10.8) as predictors of in-hospital mortality. Compared to single-valve endocarditis, multiple-valve disease was associated more frequently with heart failure (65% vs. 50%, p = 0.03), perivalvular complications (41% vs. 21%, p0.001), and heart surgery (70% vs. 54%, p = 0.002). Despite these differences, in-hospital mortality was similar (28% vs. 30%, p = 0.647). In conclusion, multiple-valve endocarditis has a poor clinical course. Mortality is similar to that of single-valve endocarditis, probably in relation with aggressive therapy including surgery in many patients. Heart failure and persistent infection are independent predictors of death.

Background— The influence of age on the main epidemiological, clinical, echocardiographic, microbiological, and prognostic features of patients with infective endocarditis remains unknown. We present the series with the largest numbers and range of ages of subjects to date that analyzes the influence of age on the main characteristics of patients with isolated left-sided infective endocarditis. Furthermore, this series is the first one in which patients have been distributed according to age quartile. Methods and Results— A total of 600 episodes of left-sided endocarditis consecutively diagnosed in 3 tertiary centers were stratified into age-specific quartiles and 107 variables compared between the different groups. With increasing age, the percentage of women, previous heart disease, predisposing disease (diabetes mellitus and cancer), and infection by enterococci and Streptococcus bovis also increased. Valvular insufficiency and perforation and S taphylococcus aureus infection were more common in younger patients. The therapeutic approach differed depending on patient age because of the growing proportion of older patients who only received medical treatment. Clinical course and hospital prognosis were worse in the older patients because of increased surgical mortality among them. Conclusions— Increasing age is associated with less valvular impairment (insufficiency and perforation), a more favorable microbiological profile, and increased surgical mortality among adults with left-sided infective endocarditis.

A 22-year-old man had infective endocarditis and an aneurysm of the anterior mitral leaflet. Blood cultures grew Streptococcus viridans , and the patient was successfully treated with high-dose intravenous penicillin. A transthoracic echocardiogram …