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Spanish Collaboration on Endocarditis—Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España (GAMES)., [Aims] Patients with infective endocarditis (IE) frequently have cardiac implantable electronic devices (CIEDs). Here, we aim to define the clinical profile and prognostic factors of IE in these patients., [Methods and results] Infective endocarditis cases were prospectively identified in the Spanish National Endocarditis Registry. From 3996 IE, 708 (17.7%) had a CIED and 424 CIED-related IE (lead vegetation). Patients with a CIED were older (68 ± 11 vs. 73 ± 8 years); had more comorbidities {pulmonary disease [176 (24.8%) vs. 545 (16.7%)], renal disease [239 (33.8%) vs. 740 (22.7%)], diabetes [248 (35.0%) vs. 867 (26.6%)], and heart failure [348 (49.2%) vs. 978 (29.9%)]}; and fewer complications {intracardiac destruction [106 (15%) vs. 1077 (33.1%)], heart failure [215 (30.3%) vs. 1340 (41.1%)], embolism [107 (15.1%) vs. 714 (21.9%)], and neurological involvement [77 (10.8%) vs. 702 (21.5%)]} (all P-values, [Conclusion] Over a sixth of IE patients have a CIED. This group of patients is older, with more comorbidities and fewer IE-related complications in comparison to subjects without a CIED. In-hospital mortality was similar in patients with and without a CIED.

Purpose: To analyze the influence of adding gentamicin to a regimen consisting of β-lactam or vancomycin plus rifampicin on survival in patients suffering from Staphylococcal prosthetic valve endocarditis (SPVE). Methods: From January 2008 to September 2016, 334 patients with definite SPVE were attended in the participating hospitals. Ninety-four patients (28.1%) received treatment based on β-lactam or vancomycin plus rifampicin and were included in the study. Variables were analyzed which related to patient survival during admission, including having received treatment with gentamicin. Results: Seventy-seven (81.9%) were treated with cloxacillin (or vancomycin) plus rifampicin plus gentamicin, and 17 patients (18.1%) received the same regimen without gentamicin. The causative microorganism was Staphylococcus aureus in 40 cases (42.6%) and coagulase-negative staphylococci in 54 cases (57.4%). Overall, 40 patients (42.6%) died during hospital admission, 33 patients (42.9%) in the group receiving gentamicin and 7 patients in the group that did not (41.2%, P = 0.899). Worsening renal function was observed in 42 patients (54.5%) who received gentamicin and in 9 patients (52.9%) who did not (p = 0.904). Heart failure as a complication of endocarditis (OR: 4.58; CI 95%: 1.84–11.42) and not performing surgery when indicated (OR: 2.68; CI 95%: 1.03–6.94) increased mortality. Gentamicin administration remained unrelated to mortality (OR: 1.001; CI 95%: 0.29–3.38) in the multivariable analysis. Conclusions: The addition of gentamicin to a regimen containing vancomycin or cloxacillin plus rifampicin in SPVE was not associated to better outcome.

A comparative study of the behaviour of left-sided infective endocarditis (left-sided IE) due to Streptococcus agalactiae (GBS) with left-sided IE caused by Staphylococcus aureus (SA). A prospective, multicentre cohort study in eight public hospitals in Spain, from January 1984 to December 2015; comparative analysis and factors associated with mortality. In total, there were 1754 episodes of left-sided IE; 41 (2.3%) caused by GBS vs. 344 (19.6%) due to SA, definitive IE 39 vs. 324 cases, males, 25 vs. 213, respectively. There were no differences in age or comorbidity, and healthcare-associated acquirement was 10% vs. 43%, p 0.001. Transthoracic echocardiogram (TTE) was performed in 95% vs. 96.8% and a transesophageal echocardiogram (TEE) in 61% vs. 56%. Vegetations were detected in 80% and measured > 1 cm in a similar proportion. It affected native valves in 85.4% vs. 82.6% and late prosthetic valve in 14.6% vs. 9.6%. The course was acute in both groups. There were more skin manifestations in SA left-sided IE, 7.3% vs. 32%, p 0.001. Both groups had similar complications, but in SA, there was more renal failure, 24% vs. 45%, p 0.010. Surgical risk and operated patients were similar. Mortality was proportionally higher in the SA group, without significance 29% vs. 43% (150), p 0.09. Heart failure, septic shock and neurological deterioration conditioned mortality: HR 1.96, 1.69 and 1.37 (CI 95% 1.40–2.73; 1.19–2.39 and 0.99–1.88 respectively) and to a lesser degree SA as aetiology agent and age. Left-sided IE caused by GBS is similar in severity to left-sided IE caused by SA.

Introduction A description of infective left endocarditis at the turn of the millennium. Method A multicentre prospective study into the left endocarditis using data collected from the Andalusian cohort for the study of cardiovascular infections during 1984–2014. Results Of the 1604 endocarditis cases collected, 382 belonged to G1 (group-1, period 1983–1999) and 1222 to G2 (group-2, 2000–2014). Patients in the new millennium have a significantly higher mean age, have more comorbidity and concomitant diseases, and nosocomial and health-related endocarditis are more frequent, as well as complications. An increase in methicillin-resistant Staphylococcus aureus , Enterococcus sp., Gram-negative bacilli and Streptococcus bovis was noted. Regarding treatment, there is an increase in the use of cephalosporins and a decrease in penicillins; there is more surgery when admitted to hospital and less delay. Mortality stands at around 30% in both millennia. In the multivariate analysis, mortality was associated with: previous millennium (G1), age, Charlson index, renal failure and septic shock, and aetiologically with S. aureus. Conclusions Mortality remains stable, despite diagnostic and therapeutic improvements, because patients are older, have greater comorbidity, a closer relationship with the health care system (nosocomial) and microorganisms are more aggressive.

To evaluate the course of left-sided infective endocarditis (LsIE) in patients with liver cirrhosis (LC) analyzing its influence on mortality and the impact of surgery.Prospective cohort study, conducted from 1984 to 2013 in 26 Spanish hospitals.A total of 3.136 patients with LsIE were enrolled and 308 had LC: 151 Child-Pugh A, 103 B, 34 C and 20 were excluded because of unknown stage. Mortality was significantly higher in the patients with LsIE and LC (42.5% vs. 28.4%; p0.01) and this condition was in general an independent worse factor for outcome (HR 1.51, 95% CI: 1.23-1.85; p0.001). However, patients in stage A had similar mortality to patients without cirrhosis (31.8% vs. 28.4% p = NS) and in this stage heart surgery had a protective effect (28% in operated patients vs. 60% in non-operated when it was indicated). Mortality was significantly higher in stages B (52.4%) and C (52.9%) and the prognosis was better for patients in stage B who underwent surgery immediately (mortality 50%) compared to those where surgery was delayed (58%) or not performed (74%). Only one patient in stage C underwent surgery.Patients with liver cirrhosis and infective endocarditis have a poorer prognosis only in stages B and C. Early surgery must be performed in stages A and although in selected patients in stage B when indicated.

Grupo GAMES., [ES] Fundamento y objetivos: La toxicidad renal de ciertos antibióticos (AB) es conocida. El objetivo de nuestro trabajo es conocer el posible efecto de los tratamientos AB en el desarrollo de insuficiencia renal (IR) en pacientes con endocarditis infecciosa (EI)., Material y método: Recogida en un registro nacional multicéntrico de los datos referentes a la función renal, tanto previa como su deterioro si existiese, durante el tratamiento de las EI y relacionarlo con los posibles factores causantes, entre ellos los AB., Resultados: Entre 2008 y 2012 se han analizado 1.853 episodios de EI remitidos desde 26 centros españoles. De ellos, un 21,6% presentaban una alteración previa de la función renal. Desarrollaron IR de novo o un empeoramiento de la función renal previa un 38,7% de los casos. En aquellos pacientes que presentaban IR previa, el deterioro fue más frecuente (64 frente a 31,7%; p < 0,001). Globalmente los pacientes con IR tenían más edad (70,6 frente a 67 años; p < 0,01) y comorbilidades (índice de Charlson 5 frente a 4; p < 0,01), y la EI era por Staphylococcus aureus (32,1 frente a 16,5%; p < 0,01). El uso de AB potencialmente nefrotóxicos solo se asoció a IR en el grupo de pacientes sin IR previa (aminoglucósidos: OR = 1,47 [IC 95% 1,096-1,988], p = 0,010; aminoglucósidos-vancomicina: OR = 1,49 [IC 95% 1,069-2,09], p = 0,019])., Conclusiones: En pacientes sin IR previa, los AB nefrotóxicos se asocian a un deterioro de la función renal. En pacientes con IR previa al episodio de EI, el deterioro de renal fue más frecuente, pero parece estar más relacionado con la gravedad de la infección., [EN] Background and objectives: The possible renal toxicity of certain antibiotics (AB) is well known. The objective of our work is to know the possible effect of AB treatments in the development of renal failure (RF) in patients with infective endocarditis (IE)., Material and method: Collection from a national multi-centre registry of collection on renal function, both prior and its impairment, if any, during the treatment of IE and in relation to possible causative factors, including the use of AB., Results: Between 2008 and 2012, 1,853 episodes of IE reported from 26 Spanish centres were analysed. Of these, 21.6% had prior RF. They developed new RF or impairment of renal function in 38.7% of the cases. In patients with prior RF, impairment was more frequent (64 vs. 31.7%, P < .001). Overall, patients with RF were older (70.6 vs. 67 years, P < .01), had more comorbidities (Charlson index 5 vs. 4, P < .01), and IE by Staphylococcus aureus (32.1 vs. 16.5%, P < .01). Potentially nephrotoxic AB use was only associated with RF in patients without prior RF (aminoglycosides: OR = 1.47 [95% CI 1.096-1.988], P = .010; aminoglycosides with vancomycin: OR = 1.49 [95% CI 1.069-2.09], P = .019)., Conclusions: In patients without prior RF, the use of nephrotoxic AB is associated with impairment of renal function. In patients with RF prior to the IE episode, impairment of renal function was more frequent but appears to be more related to the severity of infection.

Background Rates of cardiac-device infections have increased in recent years, but the current incidence and risk factors for infection in patients with implantable cardioverter-defibrillators (ICDs) are not well known. Hypothesis The increasing number of ICD infections is related to accumulated pocket manipulations over time. Methods This single-center, prospective study included patients that underwent ICD implantation from 2008 to 2015. The endpoint was time to infection. Multivariate analysis was performed to identify independent risk factors related to infection. Results The study included a total of 570 patients, of whom 419 (73.5%) underwent a first implantation. Mean age was 59 ± 14 years, and 80% were male. During a median follow-up of 36 months (interquartile range, 18–61 months; 1887 patient-years), infection was identified in 26 patients (4.56%), an incidence of 14.9 × 1000 patient-years. Median time to infection was 9.7 months (interquartile range, 1.35–23.4 months), and 38.5% were late infections (beyond 12 months of follow-up). In patients with replacement implants, the incidence was 3-fold higher than in first implantations (27.7 vs 9.1 × 1000 patient-years; P = 0.002). Cox regression identified 2 independent predictors of ICD infection: cumulative number of interventions at the generator pocket (hazard ratio: 1.92, 95% confidence interval: 1.42-2.6, P < 0.001) and pocket hematoma (hazard ratio: 7.0, 95% confidence interval: 2.7-17.9, P < 0.0001). Conclusions The incidence of infection in ICD patients is greater than previously reported, largely due to late infections. Each new cumulative intervention at the same generator pocket nearly doubles the risk of infection.

Background— The purpose of this study was to assess the incidence of neurological complications in patients with infective endocarditis, the risk factors for their development, their influence on the clinical outcome, and the impact of cardiac surgery. Methods and Results— This was a retrospective analysis of prospectively collected data on a multicenter cohort of 1345 consecutive episodes of left-sided infective endocarditis from 8 centers in Spain. Cox regression models were developed to analyze variables predictive of neurological complications and associated mortality. Three hundred forty patients (25%) experienced such complications: 192 patients (14%) had ischemic events, 86 (6%) had encephalopathy/meningitis, 60 (4%) had hemorrhages, and 2 (1%) had brain abscesses. Independent risk factors associated with all neurological complications were vegetation size ≥3 cm (hazard ratio [HR] 1.91), Staphylococcus aureus as a cause (HR 2.47), mitral valve involvement (HR 1.29), and anticoagulant therapy (HR 1.31). This last variable was particularly related to a greater incidence of hemorrhagic events (HR 2.71). Overall mortality was 30%, and neurological complications had a negative impact on outcome (45% of deaths versus 24% in patients without these complications; P Conclusions— Moderate to severe ischemic stroke and brain hemorrhage were found to have a significant negative impact on the outcome of infective endocarditis. Early appropriate antimicrobial treatment is critical, and transitory discontinuation of anticoagulant therapy should be considered.

Infective endocarditis (IE) is associated with high inhospital mortality. New microbiological diagnostic techniques have reduced the proportion of patients without etiological diagnosis, but in a significant number of patients the cause is still unknown. Our aim was to study the association of the absence of microbiological diagnosis with in-hospital prognosis. Prospective cohort of 2000 consecutive patients with IE. Data were collected in 26 Spanish hospitals. Modified Duke criteria were used to diagnose patients with suspected IE. A total of 290 patients (14.8%) had negative blood cultures. Etiological diagnosis was achieved with other methods (polymerase chain reaction, serology and other cultures) in 121 (6.1%). Finally, there were 175 patients (8.8%) without microbiological diagnosis (Group A) and 1825 with diagnosis (Group B). In-hospital mortality occurred in 58 patients in Group A (33.1%) vs. 487 (26.7%) in Group B, p = 0.07. Patients in Group A had a lower risk profile than those in Group B, with less comorbidity (Charlson index 1.9 ± 2.0 vs. 2.3 ± 2.1, p = 0.03) and lower surgical risk (EuroSCORE 23.6 ± 21.8 vs. 29.6 ± 25.2, p = 0.02). However they presented heart failure more frequently (53% vs. 40%, p = 0.005). Multivariate analysis showed that the absence of microbiological diagnosis was an independent predictor of inhospital mortality (odds ratio 1.8, 95% Confidence Interval 1.1–2.9, p = 0.016). Approximately 9% of patients with IE had no microbiological diagnosis. Absence of microbiological diagnosis was an independent predictor of inhospital mortality. Sin financiación 6.189 JCR (2016) Q1, 16/126 Cardiac and Cardiovascular Systems UEM

Please refer to the article on pages 55–56 of this issue to view the questions to which these answers refer. 1. An initial diagnosis of respiratory sepsis (pneumonia and/or empyma) was made, but the serohemorrhagic nature of the pleural effusion led to the clinical suspicion of active hemorrhage into the pleural cavity. When the CT scan of the thorax was performed, it showed a sacular aneurysm of the descending aorta with perianeurysmal hematoma and a massive hemorrhagic effusion with areas of different density in the pleural cavity. A few minutes later, the patient died in cardiovascular collapse, before surgical intervention was possible. Autopsy was not authorized. Salmonella enteritidis serotype D was isolated from blood and in pleural fluid cultures. The patient thus had a sacular mycotic aneurysm of the descending aorta which ruptured towards the pleural cavity, caused by S. enteritidis. Mycotic aneurysms (MAs) caused by Salmonella species have often been described, because of the propensity of this microorganism to infect vascular sites. Salmonella. enteritidis serotypes are the most frequently reported in Europe, e.g. in Spain [1], whereas S. cholerasuis and S. typhimurium are predominant in the USA [2]. Merkin et al. found only 14 cases of thoracic aortic aneurysms produced by Salmonella species in their study of cases recorded from 1950 to 1993, and S. enteritidis serotype D was the most frequent [3]. Any Salmonella serotype can produce bacteremia, and Cohen et al. reported that 25% of people over 50 years with salmonella bacteremia had endothelial infection, demonstrating the important role played by this microorganism in the pathogenesis of intravascular infections [4]. Nevertheless, reported cases of mycotic aneurysms caused by Salmonella are scarce, and the intrathoracic location in this case is exceptional. 2. A high index of suspicion is essential if the diagnosis of mycotic aneurysm is to be made, because initial symptoms are frequently non-specific and earlydiagnosis is important forpromptandsuccessful treatment [5]. The diagnosis can be established when there are appropriate clinical findings, such as high fever and chills, or symptoms related to the location of the aneurysm (back, shoulder or abdominal pain), along with recurrent bacteremia and the demonstration of aneurysmal dilatation of the aortic wall on a CT scan of the thorax. This last finding should be confirmed by aortography. Finally, the presence of cardiovascular risk factors or established arteriosclerotic disease also supports the diagnosis. Probably, the patient had repeated ruptures, coinciding with bacteremia, that were contained by perianeurysmal inflammatory activity. Such presumed intermittent bleeding areas explain the finding of areas of different density in the pleural cavity. Cases of relapsing rupture, contained by the blood itself or by other structures such as the parietal pleura, mediastinum or retroperitoneum, have also been described [6,7]. 3. The optimal treatment is surgical debridement of the aneurysm and the restoration of arterial flow by prosthetic reconstruction in situ or by extraanatomic bypass [8]. Prolonged administration of antibiotics is required, usually for more than 6 weeks, and several authors recommend lifelong antimicrobial therapy because of high relapse rates. However, despite early surgical intervention, development of new surgical techniques, and effective bactericidal antibiotics such as ampicillin, ciprofloxacin, or third-generation cephalosporins, the mortality rate in these patients remains as high as 75% [3,8–10]. Finally, although salmonella gastroenteritis is usually a self-limiting disease, and bacteremia develops in less than 5% of all patients, certain individuals are at increased risk of invasive infection, and may benefit from preventive antimicrobial therapy. Antimicrobial therapy should be considered for neonates, persons older than 50 years, and patients with immunosuppression, cardiac valvular or mural abnormalities, or prosthetic vascular grafts.

of synovial fluid were negative after 48 h. At discharge he continued feverless and without joint manifestations. E faecalis causes a 2.4%-8% of BRCHD. Philipneri et al1 emphasizes the importance of retrieving the central catheter before an episode of bacteriemia. They observed a clear relation between maintaining the infected catheter and the appearance of osteoarticular complications in spite of the correct antibiotic treatment, which can appear up to 5 weeks after initiating the treatment. Nevertheless, the lack of vascular access, as happened in our patient, forced us to try and “save” the TC by means of sysytemic and “sealed” treatment of the TC with a high antibiotic concentration in the period between dyalisis.2 In our case, the isolation of E faecalis with the same antibiotype in blood and synovial fluid indicate that the origin of arthritis was the BRCHD, although the blood cultures after he treatment confirmed their erradication. The microorganism can nest in the knee during the acute phase and “increase” after suspending antibiotic treatment. Enterococcus spp offers intrinsic resistance to cephalosporines and is moderately sensible to penicillins, carboxipenicillins, ureidopenicillins, and carbapenems. For that reason, we used a synergic combination of penicillin and aminoglucoside3,4 for treatment. Gavalda et al5,6 has demonstrated, in vitro and in vivo, that the combination of ampicillin and ceftriaxone is synergic and of equal effectiveness than ampicillin and gentamicine in a humanized experimental model of endocarditis. Our case demonstrates that this guideline can constitute an alternative to the classic guideline in patients with renal insufficiency or intolerance to aminoglucosides.

Background Although Streptococcus anginosus group (SAG) endocarditis is considered a severe disease associated with abscess formation and embolic events, there is limited evidence to support this assumption. Methods We performed a retrospective analysis of prospectively collected data from consecutive patients with definite SAG endocarditis in 28 centers in Spain and Italy. A comparison between cases due to SAG endocarditis and viridans group streptococci (VGS) or Streptococcus gallolyticus group (SGG) was performed in a 1:2 matched analysis. Results Of 5336 consecutive cases of definite endocarditis, 72 (1.4%) were due to SAG and matched with 144 cases due to VGS/SGG. SAG endocarditis was community acquired in 64 (88.9%) cases and affected aortic native valve in 29 (40.3%). When comparing SAG and VGS/SGG endocarditis, no significant differences were found in septic shock (8.3% vs 3.5%, P = .116); valve disorder, including perforation (22.2% vs 18.1%, P = .584), pseudoaneurysm (16.7% vs 8.3%, P = .108), or prosthesis dehiscence (1.4% vs 6.3%, P = .170); paravalvular complications, including abscess (25% vs 18.8%, P = .264) and intracardiac fistula (5.6% vs 3.5%, P = .485); heart failure (34.7% vs 38.9%, P = .655); or embolic events (41.7% vs 32.6%, P = .248). Indications for surgery (70.8% vs 70.8%; P = 1) and mortality (13.9% vs 16.7%; P = .741) were similar between groups. Conclusions SAG endocarditis is an infrequent but serious condition that presents a prognosis similar to that of VGS/SGG., In this multicenter matched cohort study, we found that Streptococcus anginosus group endocarditis follows a similar course to endocarditis caused by viridans or gallolyticus group streptococci, regarding valvular complications and prognostic variables such as indication for surgery and mortality.