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Infective endocarditis (IE) remains one of the most serious diseases with a high morbidity and mortality rate. Although the condition is more common in the medical field in a hospital setting, dentists must have a thorough understanding of the overall pathogenesis, epidemiology, risk factors and signs and symptoms that may be present in their patient population. In 2021, the American Heart Association (AHA) updated its guidelines on IE, emphasizing the specific criteria that put a patient at risk of acquiring IE, specific dental procedures that can increase the risk of IE by inducing bacteremia and an antibiotic prophylaxis regimen to act as a preventive measure if needed. This literature review gives the dental practitioner a general overview of the AHA guidelines as well as information on prevention in their at-risk patients and the need to emphasize a well-structured, consistent daily oral hygiene routine.

Background: Previous studies have elucidated the relationship between causative organism and outcomes in infective endocarditis, however this relationship has not been studies in United States Veterans. The aim of this manuscript is to evaluate the association between causative organism and short-term and long-term outcomes in United States (US) Veterans with infective endocarditis (IE) requiring surgical management between 2010-2020., Methods: We analyzed 489 patients with surgically treated IE from the Veterans Affairs (VA) Surgical Quality Improvement Program and the VA Informatics and Computing Infrastructure databases. Patients were divided into groups using causative organism identified from blood or intraoperative cultures - Staphylococcus, Streptococcus, Gram-negative rods, Enterococcus, Polymicrobial, and Unknown/Culture Negative. Other identified organisms were excluded from analysis. Cox proportional hazard models were used to calculate risk for stroke/transient ischemic attack (TIA), myocardial infarction (MI), and death based on group. The models were adjusted for covariates using backward elimination. Continuous variables were compared using ANOVA or Kruskal-Wallis H tests, and categorical variables were compared using Chi square tests., Results: Mean follow-up was 4.0 ± 6.3 years. Gram negative rods (GNRs) were associated with greater risk of long-term mortality (adjusted hazard ratios (aHR) 2.15, 95% CI: 1.20-3.86, p = 0.01). Enterococcus was associated with long-term risk of MI (aHR 2.05, 95% CI: 1.07-3.94, p = 0.03). Resistant organisms, such as methicillin-resistant staphylococcus aureus, were associated with long-term risk of MI (aHR 2.51, 95% CI: 1.14-5.45, p = 0.02). Polymicrobial infections were associated with greater risk of perioperative complications, including prolonged mechanical ventilation (48 hrs) (aHR 1.76, 95% CI: 1.05-2.97, p = 0.034), tracheostomy (aHR 5.64, 95% CI: 2.35-13.55, p < 0.001), and prolonged ICU stay (5 days) (aHR 1.39, 95% CI: 1.01-1.91, p = 0.043)., Conclusions: In US Veterans, polymicrobial infections had notably worse perioperative outcomes but similar long-term outcomes in comparison to monomicrobial infections. GNR infections were associated with increased long-term mortality. Enterococcus and resistant organisms were associated with increased long-term risk of MI. Polymicrobial infections were associated with greater risk of perioperative complications, including prolonged mechanical ventilation, tracheostomy, and prolonged ICU stay.

Renal transplant (RT) recipients are susceptible to infections because of immunosuppression. The literature regarding the epidemiology and outcomes of infective endocarditis (IE) in RT recipients is limited. We analyzed the National Inpatient Sample in the United States to study IE in RT and identify risk factors for inpatient mortality and IE development in RT patients. All patients ≥18 years who had IE with and without RT between 2007 and 2019 were identified from the National Inpatient Sample. The demographics, co-morbidities, length of stay, hospital costs, and mortality of IE patients with RT were compared with IE patients without RT. Predictors of inpatient mortality for RT recipients with IE were analyzed. Between 2007 and 2019, there were 777,245 hospitalizations for IE, of which 3,782 had RT. The IE in RT cohort was younger than the general IE population and had higher proportions of males, non-White races, and Hispanic ethnicity, and higher burden of co-morbidities, but similar inpatient mortality rates. On multivariate analysis, Staphylococcal IE (adjusted odds ratio [aOR] 2.26, 95% confidence interval [CI] 1.2 to 4.3, p = 0.015), stroke (aOR 6.4, 95% CI 2.7 to 15.3, p <0.001), anemia (aOR 2.3, 95% CI 1.3 to 4.0, p = 0.004), and shock (aOR 6.3, 95% CI 3.3 to 11.9, p <0.001) were associated with greater inpatient mortality, whereas Streptococcal endocarditis (aOR 0.37, 95% CI 0.1 to 0.9, p = 0.038) was associated with lower inpatient mortality. In conclusion, RT patients with IE were younger and had more severe co-morbidities compared with IE patients without RT. Staphylococcal IE, presence of shock and stroke worsened the prognosis in these patients., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The incidence of infective endocarditis (IE) has increased globally in the past decades, including in the United States. However, little is known about the differences in trends across states, gender, and age groups within the United States. Using the Global Burden of Disease database, we analyzed the incidence and mortality trends of IE in the United States between 1990 and 2019 using Joinpoint regression analyses, and compared between states, gender, and age groups. The age-standardized incidence rate (ASIR) of IE in the United States increased from 10.2/100,000 population in 1990 to 14.4 in 2019. The increase in ASIR was greater among men than women (45.8% vs 34.1%). The incidence increase was driven by 55+ year-olds (112.7% increase), with rapid increases in the 1990s and early 2000s, followed by a plateau around the mid-2000s. In contrast, the incidence among 5-to-19-year-olds decreased by -36.6% over the 30-year period. The incidence increased among all age groups in the last 5 years of observation (2015 to 2019), with the largest increase in 5-to-19-year-olds (3.3% yearly). The 30-year increase in ASIR was greatest in Utah (66.2%) and smallest in California (30.2%). The overall age-standardized mortality attributable to IE increased in the United States by 126% between 1990 and 2019 versus 19.6% globally. In conclusion, although the overall incidence and mortality of IE increased over the past 30 years in the United States, there are significant differences between regions, gender, and age groups. These findings indicate unevenly distributed disease burden of IE across the nation., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Infective endocarditis (IE) is associated with marked morbidity and mortality in the United States and parallels the opioid pandemic. Few studies explore this interaction and its effect on clinical outcomes. We analyzed contemporary patients admitted with IE to determine predictors of readmission in the United States. The 2017 National Readmission Database was used to identify index admissions in adults with the diagnosis of IE, based on the International Classification of Disease, 10th Revision codes. The primary outcome of interest was 30-day readmission. Secondary outcomes were mortality, hospital charges, and predictors of hospitalization readmission. Of 40,413 index admissions for IE, 5,558 patients (13.8%) were readmitted within 30 days. Patients who were readmitted were younger (55 ± 20 vs 61 ± 19 years, p <0.001) and more likely to have end-stage renal disease (12.2% vs 10.5%, p <0.001), hepatitis C virus (19.4% vs 12.6%, p <0.001), HIV (1.8% vs 1.2%, p = 0.001), opioid abuse (23.9% vs 15%, p <0.001), cocaine use (7.3% vs 4.4%, p <0.001), and other substance abuse (8.5 vs 5.6, p <0.001). Patients readmitted were less likely to have diabetes mellitus (27.8% vs 29.4%, p = 0.01), hypertension (56.9% vs 64%, p <0.001), heart failure (37.7% vs 40%, p <0.001), chronic kidney disease (31.2% vs 32%, p <0.001), and peripheral vascular disease (3.6% vs 4.6%, p = 0.001). The median cost of index admission for the total cohort was $84,325 (39,922 to 190,492). After adjusting for age, diabetes mellitus, heart failure, hypertension, and end-stage renal disease, opioid abuse (odds ratio [OR] 1.34; 95% confidence interval [CI] 1.23 to 1.46; p <0.001), cocaine use (OR 1.32; 95% CI 1.17 to 1.48; p <0.001), other substance abuse (OR 1.16; 95% CI 1.04 to 1.30; p = 0.008), and hepatitis C virus (OR 1.32; 95% CI 1.21 to 1.43; p <0.001) correlated with higher odds of 30-day readmission. These factors may present targets for future intervention., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) is recommended to prevent infective endocarditis (IE) in those at high IE risk, but there are sparse data supporting a link between IDPs and IE or AP efficacy in IE prevention., Objectives: The purpose of this study was to investigate any association between IDPs and IE, and the effectiveness of AP in reducing this., Methods: We performed a case-crossover analysis and cohort study of the association between IDPs and IE, and AP efficacy, in 7,951,972 U.S. subjects with employer-provided Commercial/Medicare-Supplemental coverage., Results: Time course studies showed that IE was most likely to occur within 4 weeks of an IDP. For those at high IE risk, case-crossover analysis demonstrated a significant temporal association between IE and IDPs in the preceding 4 weeks (OR: 2.00; 95% CI: 1.59-2.52; P = 0.002). This relationship was strongest for dental extractions (OR: 11.08; 95% CI: 7.34-16.74; P < 0.0001) and oral-surgical procedures (OR: 50.77; 95% CI: 20.79-123.98; P < 0.0001). AP was associated with a significant reduction in IE incidence following IDP (OR: 0.49; 95% CI: 0.29-0.85; P = 0.01). The cohort study confirmed the associations between IE and extractions or oral surgical procedures in those at high IE risk and the effect of AP in reducing these associations (extractions: OR: 0.13; 95% CI: 0.03-0.34; P < 0.0001; oral surgical procedures: OR: 0.09; 95% CI: 0.01-0.35; P = 0.002)., Conclusions: We demonstrated a significant temporal association between IDPs (particularly extractions and oral-surgical procedures) and subsequent IE in high-IE-risk individuals, and a significant association between AP use and reduced IE incidence following these procedures. These data support the American Heart Association, and other, recommendations that those at high IE risk should receive AP before IDP., Competing Interests: Funding Support and Author Disclosures This study was funded by a research grant from the Delta Dental of Michigan Research Committee and Renaissance Health Service Corporation. The views expressed in this publication are those of the authors and do not necessarily represent those of the funders. The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review or approval of the manuscript; or the decision to submit the manuscript for publication. Profs Thornhill, Lockhart, and O’Gara have received support from the Delta Dental Research and Data Institute for this work. Dr Dayer has received support in the last 3 years from Biotronik that was unconnected to the submitted work; and was a consultant to the review committee that produced the 2015 update to NICE clinical guideline 64 on prophylaxis against infective endocarditis. Prof Prendergast has received unrestricted research and educational grants from Edwards Lifesciences; has received lecture fees from Abbott, Anteris, and Edwards Lifesciences; and has received consultancy fees from and serves on the Scientific Advisory Board for Anteris and Microport (all unconnected to the submitted work); was a member of the Task Force on the Prevention, Diagnosis and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC) that produced the 2009 ESC guidelines; and acted as an external advisor to the committee that produced NICE clinical guideline 64 on Prophylaxis Against Infective Endocarditis in March 2008. Dr Lockhart is a member of the writing committee reviewing the current AHA guidelines on antibiotic prophylaxis to prevent infective endocarditis. Drs Lockhart and Baddour were members of the AHA Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, and were involved in producing both the 2007 and 2021 AHA guidelines on prevention of infective endocarditis. Dr O’Gara has received support in the last 3 years from Medtronic, Edwards Scientific, and the National Heart, Lung, and Blood Institute that was unconnected to the submitted work. Dr Baddour has received royalty payments (authorship duties) from UpToDate, Inc; and has received consulting fees from Boston Scientific, Botanix Pharmaceuticals, and Roivant Sciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Infective endocarditis due to Bartonella species is rare. The clinical and echocardiographic characteristics are not well defined. We aimed to investigate the clinical and echocardiographic findings of Bartonella endocarditis in the contemporary era., Methods: The infective endocarditis (IE) registry and echocardiographic database at our institution were retrospectively analysed to evaluate the clinical and echocardiographic features of Bartonella endocarditis., Results: Between January 2008 and December 2015, there were 11 patients with Bartonella IE (0.84% among a total of 1,308 cases of definite IE): median age 54 (30-69) years, all male, 9 Caucasian, 10 had a history of cat exposure, 10 had a pre-existing valvulopathy including 6 patients with a prosthetic valve with prosthesis age range between 3 to 5 years and 1 patient with implantable cardioverter defibrillator (ICD). Bartonella henselae was responsible for all the cases. Echocardiographic evidence of IE was found in 6 of 11 patients on transthoracic echocardiography (TTE), and 6 of 8 on transoesophageal echocardiography (TEE). Bartonella IE was associated with significant valvular destruction and dysfunction on echocardiography. Nine (9) patients were managed surgically with excellent outcomes, including two patients who failed initial medical therapy. Two (2) patients who were managed medically had progression of valvular dysfunction. At a median follow-up of 6 months, there were no deaths attributable to IE or other cardiovascular causes., Conclusion: In a contemporary single-centre cohort in the United States, Bartonella IE remains rare, but should be considered when pathogen could not be identified in patients with suspected IE, especially those with prosthetic valves or bicuspid aortic valve (BAV). The vast majority of patients with Bartonella IE were managed surgically with excellent outcomes., (Copyright © 2021 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Introduction: The epidemiology of infective endocarditis (IE) in this millennium has changed with emergence of new risk factors and reemergence of others. This, coupled with modifications in national guidelines in the setting of a pandemic, prompted an address of the topic., Areas Covered: Our goal is to provide a contemporary review of IE epidemiology considering changing incidence of rheumatic heart disease (RHD), cardiac device implantation, and injection drug use (IDU), with SARS-CoV-2 pandemic as the backdrop., Methods: PubMed and Google Scholar were used to identify studies of interest., Expert Opinion: Our experience over the past two decades verifies the notion that there is not one 'textbook' profile of IE. Multiple factors have dramatically impacted IE epidemiology, and these factors differ, based, in part on geography. RHD has declined in many areas of the world, whereas implanted cardiovascular devices-related IE has grown exponentially. Perhaps the most influential, at least in areas of the United States, is injection drug use complicating the opioid epidemic. Healthy younger individuals contracting a potentially life-threatening infection has been tragic. In the past year, epidemiological changes due to the COVID-19 pandemic have also occurred. No doubt, changes will characterize IE in the future and serial review of the topic is warranted.

To evaluate trends in bacterial causes of valvular endocarditis in swine, we retrospectively analyzed 321 cases diagnosed at Iowa State University Veterinary Diagnostic Laboratory (Ames, IA, USA) during May 2015--April 2020. Streptococcus gallolyticus was the causative agent for 7.59% of cases. This emerging infection in swine could aid study of endocarditis in humans.

Background: Prosthetic valve endocarditis (PVE) carries high mortality and morbidity as compared to native valve endocarditis (NVE). Contemporary data on PVE are lacking, we aimed to study contemporary trends, outcomes, and burden of PVE using nationally representative data., Methods: We used the National Inpatient Sample from 2000 to 2017 to identify patients admitted with PVE using ICD-9-CM and ICD-10 codes. Risk-adjusted rates were calculated using an Analysis of Covariance (ANCOVA) with the Generalized Linear Model (GLM). Trends were assessed with linear regression and Pearson's Chi-square when appropriate. Binomial logistic regression was used to assess predictors of in-hospital mortality., Results: We identified 43,602 hospitalizations for PVE. PVE hospitalizations increased from 1803 in 2000 to 3450 in 2017. Risk-adjusted mortality decreased from 10.7% in 2002 to 7.3% in 2017 (P<0.01). Logistic regression analysis on mortality showed increase association with age (OR, 1.021, 95%CI [1.017-1.024], p<0.01), Hispanics (OR, 1.493, 95%CI [1.296-1.719], p<0.01) and patients with drug abuse (OR, 1.233, 95%CI [1.05-1.449], p=0.01). Co-morbid conditions like congestive heart failure (OR, 1.511, 95%CI [1.366-1.673], p<0.01), renal failure (OR, 1.572, 95%CI [1.427-1.732], p<0.01) and weight loss (OR, 1.425, 95%CI [1.093-1.419], p<0.01) were also associated with higher mortality., Conclusions: Over the years the adjusted in-hospital mortality in PVE has trended down but the average cost of stay has increased despite decrease in length of stay., (Copyright © 2021 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Infective endocarditis (IE) is a life-threatening disease caused by bacterial adherence to the lining of the heart and heart valve, and it can be caused by bacterial contamination of the bloodstream during invasive dental procedures. The American Heart Association (AHA) recommended guidelines for antibiotic prophylaxis in 2008 before invasive dental procedures; however, in the Dominican Republic, no official guidelines or regulations on this topic have been yet established. This study aimed to evaluate the current knowledge about bacterial endocarditis prevention among dentists in Santo Domingo. The study participants were dentists who attended a conference organized by Universidad Federico Henríquez y Carvajal ( n = 95), of which 74 responded to the questionnaire survey. Seventy-eight percentage of the participants responded that an indication of antibiotics is recommended in cases of prophylaxis for IE. The prescription of antibiotics was applied to patients with prosthetic valves (78.4%), presented a history of previous IE (77%) among others. Among all the interventions in which the respondents would prescribe antibiotics, tooth extraction (70.7%) was the most frequent. Amoxicillin was the preferred drug choice (63.5%) and clindamycin was the antibiotic of choice in allergic patients (55.4%). Even though the choice of antibiotics were according to AHA guidelines (2008), majority of the dentists (58.82 and 55.4%) were not aware of the correct dosage and timing of administration of azithromycin and clindamycin in drugs in patients allergic to penicillin., (Copyright © 2020 Aragoneses, Aragoneses, Brugal, Algar and Suarez.)

Background: The rise in the number of valve operations performed for infective endocarditis (IE) due to drug use is an important manifestation of the opioid epidemic. This study characterized national trends and outcomes of valve surgery for drug use-associated IE (DU-IE)., Methods: Adults undergoing valve surgery for active IE in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database between July 2011 and June 2018 were stratified as DU-IE and non-DU-IE. Trends and clinical profiles were analyzed. Early outcomes were assessed. The association of DU-IE with outcomes was analyzed with multivariable regression, adjusting for STS Valve Risk model covariates., Results: There were 34,905 valve operations performed for IE, of which 33.7% were for DU-IE. DU-IE operations increased 2.7-fold during the study period. There was considerable regional variability in DU-IE operations, ranging from 28% to 58% of all IE surgeries in 2018, with highest rates observed in East South Central and South Atlantic regions. DU-IE patients were younger and had fewer cardiovascular comorbidities. Risk-adjusted major morbidity and in-hospital mortality were significantly higher in the DU-IE group. Redo valve procedures in DU-IE patients were associated with worse outcomes, compared with those receiving a first valve operation., Conclusions: Operations for DU-IE have increased sharply in the United States during the last several years, exhibiting substantial regional variability. DU-IE patients have unique clinical profiles, and worse risk-adjusted outcomes. This demonstrates the significant impact of the opioid epidemic on endocarditis surgeries and punctuates the urgent need for multidisciplinary regional and national efforts to reverse this trend., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to evaluate the incidence and outcomes of endocarditis after transcatheter aortic valve replacement (TAVR)., Background: Data about endocarditis after TAVR are limited., Methods: The study investigated Medicare patients who underwent TAVR from 2012 to 2017 and identified patients admitted with endocarditis during follow-up using a validated algorithm. The main study outcome was all-cause mortality., Results: Of 134,717 patients who underwent TAVR, 1868 patients developed endocarditis during follow-up (incidence 0.87%/year), with majority of infections (65.0%) occurring within 1 year. Incidence of endocarditis declined in recent years. The most common organisms were Staphylococcus (22.0%), Streptococcus (20.0%), and Enterococcus (15.5%). Important predictors for endocarditis were younger age at TAVR, male sex, prior endocarditis, end-stage renal disease, repeat TAVR procedures, liver and lung disease, and post-TAVR acute kidney injury. Thirty-day and 1-year mortality were 18.5% and 45.6%, respectively. After adjusting for comorbidities and procedural complications, endocarditis after TAVR was associated with 3-fold higher risk of mortality (44.9 vs. 16.2 deaths per 100 person-years; adjusted hazard ratio [aHR]: 2.94; 95% confidence interval [CI]: 2.77 to 3.12; p < 0.0001). End-stage renal disease (aHR: 2.12; 95% CI: 1.72 to 2.60), endocarditis complicated by cardiogenic shock (aHR: 2.50, 95% CI: 1.56 to 4.02), ischemic stroke (aHR: 1.56; 95% CI: 1.07 to 2.28), intracerebral hemorrhage (aHR: 1.67; 95% CI: 1.01 to 2.76), acute kidney injury (aHR: 1.44; 95% CI: 1.27 to 1.63), blood transfusion (aHR: 1.28; 95% CI: 1.09 to 1.50), staphylococcal (aHR: 1.71; 95% CI: 1.49 to 1.97), and fungal endocarditis (aHR: 1.72; 95% CI: 1.23 to 2.39) (p < 0.05 for all) portended higher mortality following endocarditis., Conclusions: The incidence of endocarditis after TAVR is low and declining. However, it is associated with poor prognosis with one-half the patients dying within 1 year., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Infective endocarditis (IE) with non-HACEK Gram-negative (GN) organisms is rare, but associated with poor outcomes. The purpose of this study was to quantify the microbiology, treatment strategies, and frequency of poor outcomes in patients with non-HACEK GN IE., Materials: Retrospective cohort of adults with definite non-HACEK GN IE from 1/11-1/19. The primary endpoint was poor patient outcome, defined as a composite of all-cause death or infection-related readmission within 90-days of index infection., Results: 43 patients were included: 51% patients were men, and the median (IQR) age was 40 (31-50) years. Forty patients reported injection drug use. The most common organisms were Pseudomonas aeruginosa (68%) and Serratia marcescens (9%). Seventy-six percent of patients received definitive combination therapy; the most common antibiotics used in combination with a β-lactam were aminoglycosides (50%) and fluoroquinolones (34%). Three patients discontinued combination therapy due to toxicity. Twelve-month, all-cause mortality and readmission was 30% and 54%, respectively. In multivariable logistic regression, variables independently associated with composite poor outcome were receipt of fluoroquinolone-based IE combination therapy and septic shock., Conclusions: Long-term mortality and readmission rates were high. Patients who received fluoroquinolone-based IE combination therapy more frequently developed poor outcomes than those who did not., Competing Interests: The authors have declared that no competing interests exist.

Background: In 2007, the American Heart Association recommended antibiotic prophylaxis for the prevention of infective endocarditis (IE) for only the highest-risk patients. Whether this change affected the use of antibiotic prophylaxis and the incidence of IE is unclear., Methods: IE-related hospitalizations were identified from 2002 to 2014 among all adults and those at high and moderate risk for IE, stratified by age. Prescriptions for antibiotic prophylaxis were obtained from the Ontario Drug Benefit database for adults ≥65 years of age. Outcomes were antibiotic prophylaxis prescription rates and incidence of IE-related hospitalization. Trends in patient and pathogen characteristics were analyzed. Time series analyses were performed with segmented regression and change-point analyses., Results: Prescriptions for antibiotic prophylaxis decreased substantially in the moderate-risk cohort after the guideline revision (mean quarterly prescriptions, 30 680 versus 17 954 [level change, -6,481; P=0.0004] per 1 million population) with a minimal, yet significant, decrease followed by a slow increase in the high-risk group. There were 7551 IE-related hospitalizations among 6884 adults ≥18 years of age. Among adults ≥65 years of age, the mean IE rate increased from 872 to 1385 and 229 to 283 per 1 million population at risk per quarter in the high- and moderate-risk groups, respectively. Change-point analyses indicated that this increase occurred in the second half of 2010 in adults ≥65 years of age, 3 years after the American Heart Association guideline revision. Staphylococcus aureus and streptococcal species accounted for 30.3% and 26.4% of all IE, with a decrease in streptococcal infections over time., Conclusions: Antibiotic prophylaxis decreased significantly in the moderate-risk group with minimal change in the high-risk group after the American Heart Association guideline revision in 2007. However, IE-related hospitalizations increased among both high- and moderate-risk patients 3 years after the revision. Our study provides support for the cessation of antibiotic prophylaxis in the moderate-risk population.

Background: Bacterial infection is a major cause of morbidity and mortality for persons who inject drugs (PWID). Injection cessation may help abrogate such infections, but maintaining complete cessation is challenging. Limited data exists on the role of reduced injection intensity on invasive bacterial infection risk. We sought to evaluate decreased risk for bacterial infections following cessation and substantive reduction in the injection intensity., Methods: Participants were persons in the AIDS Linked to the Intravenous Experience (ALIVE) cohort with initial high-frequency injection drug use (> 1 daily). Pooled logistic regression with generalized estimating equations was used to estimate risk for invasive bacterial infection (pneumonia, endocarditis, or sepsis) among participants achieving complete injection cessation or reduced injection intensity relative to those with sustained high-frequency use., Results: Of 2247 study participants with 12,469 paired study visits, complete injection cessation was achieved at 13.5% and reduced injection intensity at 25.5% of study visits. Adjusting for sociodemographics and HIV status, injection cessation was associated with a 54% reduction of bacterial infection at 3 months (odds ratio [OR] 0.46, 95% CI 0.25-0.84) and a 46% reduction at 6 months (OR 0.54, 95% CI 0.36-0.81). Reduced injection intensity was associated with a 36% reduction of infection at 3 months (OR 0.64, 95% CI 0.43-0.96) and a 26% reduction at 6 months (OR 0.74, 95% CI 0.56-0.98)., Conclusions: Both complete cessation and reduced injection frequency demonstrate substantial benefit in reducing invasive bacterial infection risk among PWID. With high rates of relapse into injection use, targeting sustained reductions in drug use intensity may be a key harm reduction modality for improving clinical outcomes in this population.

Background: The American Heart Association updated its recommendations for antibiotic prophylaxis (AP) to prevent infective endocarditis (IE) in 2007, advising that AP cease for those at moderate risk of IE, but continue for those at high risk., Objectives: The authors sought to quantify any change in AP prescribing and IE incidence., Methods: High-risk, moderate-risk, and unknown/low-risk individuals with linked prescription and Medicare or commercial health care data were identified in the Truven Health MarketScan databases from May 2003 through August 2015 (198,522,665 enrollee-years of data). AP prescribing and IE incidence were evaluated by Poisson model analysis., Results: By August 2015, the 2007 recommendation change was associated with a significant 64% (95% confidence interval [CI]: 59% to 68%) estimated fall in AP prescribing for moderate-risk individuals and a 20% (95% CI: 4% to 32%) estimated fall for those at high risk. Over the same period, there was a barely significant 75% (95% CI: 3% to 200%) estimated increase in IE incidence among moderate-risk individuals and a significant 177% estimated increase (95% CI: 66% to 361%) among those at high risk. In unknown/low-risk individuals, there was a significant 52% (95% CI: 46% to 58%) estimated fall in AP prescribing, but no significant increase in IE incidence., Conclusions: AP prescribing fell among all IE risk groups, particularly those at moderate risk. Concurrently, there was a significant increase in IE incidence among high-risk individuals, a borderline significant increase in moderate-risk individuals, and no change for those at low/unknown risk. Although these data do not establish a cause-effect relationship between AP reduction and IE increase, the fall in AP prescribing in those at high risk is of concern and, coupled with the borderline increase in IE incidence among those at moderate risk, warrants further investigation., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Little is known about the magnitude of the association between infective endocarditis and cancer, and about the natural history of cancer patients with concomitant diagnosis of infective endocarditis. We used the SEER-Medicare linked database to identify individuals aged 65 years or more diagnosed with colorectal, lung, breast, or prostate cancer, and without any cancer diagnosis (5% random Medicare sample from SEER areas) between 1992 and 2009. We identified infective endocarditis from the ICD-9 diagnosis of each admission recorded in the Medpar file and its incidence rate 90 days around cancer diagnosis. We also estimated the overall survival and CRC-specific survival after a concomitant diagnosis of infective endocarditis. The peri-diagnostic incidence of infective endocarditis was 19.8 cases per 100,000 person-months for CRC, 5.7 cases per 100,000 person-months for lung cancer, 1.9 cases per 100,000 person-months for breast cancer, 4.1 cases per 100,000 person-months for prostate cancer and 2.4 cases per 100,000 person-months for individuals without cancer. Two-year overall survival was 46.4% (95% CI 39.5, 54.5%) for stage I-III CRC patients with concomitant endocarditis and 73.1% (95 % CI 72.9, 73.3%) for those without it. In this elderly population, the incidence of infective endocarditis around CRC diagnosis was substantially higher than around the diagnosis of lung, breast and prostate cancers. A concomitant diagnosis of infective endocarditis in patients with CRC diagnosis is associated with shorter survival.

Colonization with Staphylococcal aureus is markedly more frequent in individuals with atopic dermatitis (AD) than in unaffected individuals. Chronic scratching leads to worsening of an existing defect in the epidermal barrier, which can allow S. aureus invasion into the bloodstream and subsequent systemic infections. We report two unusual cases of systemic illness in individuals with AD. One developed infective endocarditis followed by a stroke and the other developed septic arthritis and osteomyelitis. We performed an extensive literature review of reported systemic complications caused by S. aureus in patients with AD. Although reports are rare, practitioners should be aware of these important, albeit unlikely, complications of staphylococcal superinfections in individuals with AD., (© 2015 Wiley Periodicals, Inc.)

This study aimed to determine current practices regarding prophylaxis against infective endocarditis among pediatric cardiologists in the United States 5 years after publication of the most recent American Heart Association (AHA) recommendations. A descriptive, analytical, cross-sectional study was conducted from June 2012 to November 2012 in the format of an anonymous self-administered e-mailed questionnaire among pediatric cardiologists across the United States. The questionnaire inquired about demographic information of cardiologists and their current practices of prescribing preprocedure antibiotic prophylaxis against endocarditis to patients with specific preexisting cardiac conditions. Descriptive analyses were done in percentages. Frequency and exploratory statistical analyses were done by the Chi-square method. Of the 980 cardiologists invited, 221 (23 %) responded to the survey. The findings showed that pediatric cardiologists generally follow the AHA guidelines. The most common cardiac conditions in which antibiotics were administered despite AHA guidelines not requiring prophylaxis were rheumatic heart disease with aortic insufficiency, transposition of the great vessels after the Mustard procedure, bicuspid aortic valve with severe aortic stenosis, cardiac transplantation without valvar disease, and bicuspid aortic valve with severe aortic insufficiency. More experienced pediatric cardiologists were significantly more likely to administer prophylaxis to certain patients than their less experienced peers. Many pediatric cardiologists in the United States continue to administer preprocedure antibiotic prophylaxis against endocarditis even when not recommended to do so per the 2007 AHA guidelines. With certain lesions, highly experienced pediatric cardiologists are more likely to administer prophylaxis than their less experienced counterparts.

Eighty-one endocarditis-derived Enterococcus faecalis isolates that were collected from individual patients in the United States between 1974 and 2004 were sequence typed and analyzed for the presence of various genes, including some previously associated with virulence. Overall, using our previously described trilocus sequence typing (TLST), 44 different sequence types (STs) were found within this collection; 26 isolates were singletons (a unique TLST sequence type [ST(T)]), some ST(T)s contained multiple isolates (up to 6 isolates), and 16% of the isolates (13 isolates) could be grouped by additional sequence typing into clonal cluster 21 (CC21). Of note, only four isolates (7%) of the 56 whose multilocus sequence types were determined were found to belong to one of the previously described hospital-associated clonal clusters CC2 and CC9, and only 15% and 37% of all isolates had high-level resistance to gentamicin and streptomycin, respectively, including 10% that were resistant to both. We also found that 64% of the isolates lacked the genes for production of capsule polysaccharide, which has been proposed to enhance the pathogenic potential of the hospital-associated clonal clusters. In summary, while our collection is not a random sample of cases of E. faecalis endocarditis, these results indicate that nonencapsulated strains belonging to non-hospital-associated lineages were predominant among endocarditis E. faecalis isolates recovered during this time period.

Background: The American Heart Association published updated guidelines for infective endocarditis (IE) prevention in 2007 that markedly restricted the use of antibiotic prophylaxis in certain at-risk patients undergoing dental and other invasive procedures. The incidence of IE caused by viridans group streptococci (VGS) in the United States after publication of the 2007 American Heart Association guidelines has not been reported., Methods and Results: We performed a population-based review of all definite or possible cases of VGS-IE using the Rochester Epidemiology Project of Olmsted County, Minnesota. Patient demographics and microbiological data were collected for all VGS-IE cases diagnosed from January 1, 1999, through December 31, 2010. We also examined the Nationwide Inpatient Sample hospital discharge database to determine the number of VGS-IE cases included between 1999 and 2009. We identified 22 cases with VGS-IE in Olmsted County over the 12-year study period. Rates of incidence (per 100 000 person-years) during time intervals of 1999-2002, 2003-2006, and 2007-2010 were 3.19 (95% confidence interval, 1.20-5.17), 2.48 (95% confidence interval, 0.85-4.10), and 0.77 (95% confidence interval, 0.00-1.64), respectively (P=0.061 from Poisson regression). The number of hospital discharges with a VGS-IE diagnosis in the Nationwide Inpatient Sample database during 1999-2002, 2003-2006, and 2007-2009 ranged between 15 318 to 15 938, 16 214 to 17 433, and 14 728 to 15 479, respectively., Conclusions: On the basis of data complete through 2010, there has been no perceivable increase in the incidence of VGS-IE in Olmsted County, Minnesota, since the publication of the 2007 American Heart Association endocarditis prevention guidelines.

Staphylococcus lugdunensis is a virulent coagulase-negative staphylococcus (CoNS) that behaves like Staphylococcus aureus. Toxic shock syndrome, osteomyelitis, septic arthritis and postoperative endopthalmitis have been observed. Endocarditis complicated by heart failure, periannular abscess formation and embolic phenomenon have brought particular attention to this CoNS. Mortality rates for endocarditis appear higher when compared with other CoNS. Owing to the laboratory methods used, identification may be misleading. β-lactam antimicrobials are recommended pending sensitivities. Evaluation for endocarditis should be pursued in bacteremic patients due to its pathogenic potential.

Background: Cardiovascular implantable electronic device (CIED) infections have been increasing out of proportion to the number of devices implanted, based on data available through 2003. We investigated recent trends and possible causes of the increasing numbers of CIED infections., Methods: We analyzed the occurrence of CIED infections and the associated changes in characteristics of CIED recipients, using the National Hospital Discharge Survey database from 1996 through 2006., Results: The number of CIED implantations continued to increase after 2003 from 199,516 in 2004 to 222,940 in 2006, representing a 12% increment. In the same period, the number of CIED infections increased from 8,273 in 2004 to 12,979 in 2006, representing a 57% increment. From 1996 to 2006, comorbid illnesses in recipients of new CIED devices became more prevalent with an increasing percentage of patients with end-organ failures (6.5% in 1996 vs 8.0% in 2006, P < 0.001) and diabetes mellitus (14.5% in 1996 vs 16.5% in 2006, P = 0.005). The proportion of Caucasian recipients also decreased (65.6% in 1996 vs 57.6% in 2006, P < 0.001). During that same period, the number of implanted cardiac resynchronization devices increased dramatically while the age of CIED recipients did not change., Conclusion: The number of patients with CIED-related infections in the United States continues to increase out of proportion to the increase in implantation rates. Possible causes for this on-going epidemic include sicker patients with varying racial backgrounds, and more complex procedures. These insights may help improve our ability to best select patients for CIED implantation in "real-life" settings. (PACE 2010; 414-419).

Importance of the Field: Despite significant advances in medical, surgical, and critical care interventions, infective endocarditis (IE) remains a disease associated with considerable morbidity and mortality. Estimates from the American Heart Association place the incidence of IE in the US at 10,000 - 15,000 new cases each year. This may be due to the changing epidemiology of IE, including increasing antimicrobial resistance, increasing heart surgeries, prosthetic valve implantation, and widespread use of intravenous drugs. Furthermore, a new form of the disease, healthcare-associated IE, which is associated with new therapeutic modalities such as intravenous catheters, hyperalimentation lines, pacemakers, and dialysis shunts, has emerged., Areas Covered in This Review: We present the latest therapeutic and preventive strategies for IE caused by a variety of bacterial and fungal pathogens. The general methods employed included an extensive literature search, confined to the last 10 years, using key words such as 'infective endocarditis', 'culture-negative endocarditis', 'treatment guidelines for IE', and 'prophylaxis for IE'., What the Reader Will Gain: Comprehensive information regarding the changing epidemiology of IE is provided. The latest guidelines with respect to therapy and prophylaxis of IE are reviewed., Take Home Message: Successful management of IE depends on maintaining a high index of suspicion for the disease and, when IE is diagnosed, close cooperation of medical and surgical disciplines is required. Further research is needed to better understand and provide optimal therapy for complex situations such as multidrug-resistant and polymicrobial IE.

Background: Infective endocarditis (IE) often is caused by bacteria that colonize teeth. The authors conducted a study to determine if poor oral hygiene or dental disease are risk factors for developing bacteremia after toothbrushing or single-tooth extraction., Methods: One hundred ninety-four participants in a study were in either a toothbrushing group or a single-tooth extraction with placebo group. The authors assessed the participants' oral hygiene, gingivitis and periodontitis statuses. They assayed blood samples obtained before, during and after the toothbrushing or extraction interventions for IE-associated bacteria., Results: The authors found that oral hygiene and gingival disease indexes were associated significantly with IE-related bacteremia after toothbrushing. Participants with mean plaque and calculus scores of 2 or greater were at a 3.78- and 4.43-fold increased risk of developing bacteremia, respectively. The presence of generalized bleeding after toothbrushing was associated with an almost eightfold increase in risk of developing bacteremia. There was no significant association between any of the measures of periodontal disease and the incidence of bacteremia after toothbrushing. The oral hygiene or disease status of a tooth was not significantly associated with bacteremia after its extraction., Conclusion: Bacteremia after toothbrushing is associated with poor oral hygiene and gingival bleeding after toothbrushing., Clinical Implications: Improvements in oral hygiene may reduce the risk of developing IE.

Methicillin-resistant Staphylococcus aureus (MRSA) PFGE strain type USA300 (multilocus sequence type 8, clonal complex 8, staphylococcal cassette chromosome mec type IV) was first reported in the USA as a cause of skin and soft issue infection among college football players in Pennsylvania and among prisoners in Missouri in 2000. Over the next 5 years, USA300 became the predominant community-associated MRSA strain in the USA. It was the most common PFGE type recovered from skin and soft tissue infections in persons presenting to 11 emergency departments across the USA, and caused outbreaks in Native American populations, children in daycare centres, military recruits, prison inmates and among men who have sex with men. Although predominantly a cause of skin and soft issue infection, USA300 isolates also have been recovered from cases of invasive disease including bacteraemia, endocarditis, severe necrotizing pneumonia and osteomyelitis. Isolates of USA300 usually carry the genes encoding the Panton-Valentine leucocidin and the arginine catabolic mobile element, but rarely carry staphylococcal enterotoxin genes. USA300 isolates are becoming more resistant to antimicrobial agents, including erythromycin, levofloxacin, mupirocin and tetracycline, and have spread to Europe, South America and Australia. The emergence of the MRSA USA300 strain type represents a unique biological success story.

Infective endocarditis (IE) is becoming a disease of the elderly because of the aging process and increased use of intravascular devices. If undetected, IE has a poor prognosis. Previous guidelines had become cumbersome, and with unintended consequences, ie, excess antibiotic use, potential risk for acquisition of multiple-drug-resistant organisms and adverse drug reactions. The newest American Heart Association guideline severely restricts antibiotic prophylaxis, recommending it only for cardiac conditions with the greatest risks for complications and for dental procedures that involve perforation of oral mucosa, manipulation of gingival tissue or periapical region of the teeth. Routine prophylaxis for genitourinary and gastrointestinal procedures is no longer recommended.

Elevated troponin is increasingly recognized as a marker of cardiac injury and poor outcomes in diverse disease states. It was hypothesized that patients with infective endocarditis (IE) and elevated cardiac troponin would have more extensive IE and worse clinical outcomes. Patients were enrolled as part of the International Collaboration on Endocarditis (ICE) prospective cohort study; analysis of these patients was done retrospectively. Data from 83 consecutively enrolled patients from a single center were evaluated. Cardiac troponin I (cTnI) was drawn for clinical indications and before any cardiac surgery in 51 of the 83 patients. Outcomes evaluated were hospital mortality, annular or myocardial abscess on the basis of echocardiography or surgery, and central nervous system events. Of 51 patients with cTnI drawn, 33 (65%) had elevated cTnI > or =0.1 mg/dl. There were no differences in age, gender, prosthetic valve IE, Staphylococcus aureus IE, or history of coronary artery disease, congestive heart failure, or diabetes mellitus between patients with and without cTnI elevations. Patients with elevated cTnI were less likely to have isolated right-sided IE and more likely to have left ventricular systolic dysfunction or renal dysfunction (p <0.05 for each). In conclusion, elevated cTnI was associated with the composite of death, abscess, and central nervous system events (p <0.001).

Purpose of Review: The British Society for Antimicrobial Chemotherapy and the American Heart Association have radically revised their guidelines for the antibiotic prophylaxis of endocarditis. This review discusses the evidence behind the most controversial changes and considers possible future developments., Recent Findings: The new guidelines emphasize good oral hygiene for preventing viridans streptococcal endocarditis. Antibiotic prophylaxis for dental procedures is only recommended for patients with the highest-risk cardiac conditions. American Heart Association guidelines no longer recommend prophylaxis for urological and gastrointestinal procedures., Summary: While only up to 6% of endocarditis cases may be prevented by antibiotic prophylaxis there is controversy as to what to recommend for the individual cardiac patient undergoing a given procedure. The new guidelines about dental prophylaxis are based on epidemiological studies that failed to include sufficient subjects undergoing specific interventions. When considering viridans streptococcal rather than total bacteraemia rates, asserting that the prevalence of bacteraemia after invasive dental procedures is similar to that after toothbrushing may be incorrect. The British Society for Antimicrobial Chemotherapy report probably overestimates the risk of fatal anaphylaxis after an oral dose of amoxicillin. In contrast, the American Heart Association guidelines comment on the absence of any reports of fatal anaphylaxis associated with the antibiotic prophylaxis of endocarditis.

Infective endocarditis is a potentially fatal consequence of illicit injection drug use. We estimate that the number of hospitalization for injection drug use-related infective endocarditis increased by 38%-66% in the United States between 2000-2001 and 2002-2003, a period during which the number of at-risk persons (i.e., injection drug users) remained stable. Increasing methamphetamine use and/or drug injection frequency may have increased the incidence of infective endocarditis among active injection drug users.

Background: The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997., Methods and Results: A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee., Conclusions: The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

The periannular extension of infection in prosthetic valve endocarditis (PVE) is a serious complication of infective endocarditis associated with high mortality. Periannular lesions in PVE occasionally rupture into adjacent cardiac chambers, leading to aortocavitary fistulae and intracardiac shunting. It is unknown whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinctive clinical characteristics of patients with PVE and either aortocavitary fistulization or nonruptured abscesses. In a retrospective multicenter study of >872 PVE episodes, 150 patients (17%) with periannular complications in PVE in the aortic position were identified (29 with aortocavitary fistulization and 121 with nonruptured abscesses). Early-onset PVE was present in 73 patients (49%). Rates of heart failure (p = 0.09), ventricular septal defect (p <0.01), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 128 patients (83%). In-hospital mortality in the overall population was 39%. Multivariate analysis identified heart failure (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6 to 6.8), renal failure (OR 2.5, 95% CI 1.2 to 5.2), and co-morbidity (OR 2.4, 95% CI 1.1 to 5.1) as independent risk factors for death. Fistulous tract formation was not associated with increased in-hospital mortality (OR 1.6, 95% CI 0.7 to 3.7). The actuarial 5-year survival rate in surgical survivors was 100% in patients with fistulae and 78% in patients with nonruptured abscesses (log-rank p = 0.14). In conclusion, aortocavitary fistulous tract formation in PVE complicated with periannular complications is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscesses. Despite the frequent complications, fistulous tract formation in the current era of infective endocarditis is not an independent risk factor for mortality.

The extension of infection in native valve infective endocarditis (IE) from valvular structures to the periannular tissue is incompletely understood. It is unknown, for example, whether the prognosis of patients with aortocavitary fistulae is worse than that of those with nonruptured abscesses. The aims of this study were to determine the distinct clinical characteristics of patients with aortocavitary fistulae and nonruptured abscesses in native valve IE and to evaluate the impact of fistulization on the outcomes of patients with native aortic valve IE complicated with periannular lesions. In a retrospective multicenter study of 2,055 native valve IE episodes, 201 patients (9.8%) with periannular complications in aortic valve IE were identified (46 with aortocavitary fistulization and 155 with nonruptured abscesses). Rates of heart failure (p = 0.07), ventricular septal defect (p <0.001), and third-degree atrioventricular block (p = 0.07) were higher in patients with fistulization. Surgical treatment was undertaken in 172 patients (86%), and in-hospital mortality in the overall population was 29%. Multivariate analysis identified age >60 years (odds ratio [OR] 2.6, 95% confidence interval [CI] 1.3 to 5.2), renal failure (OR 3.0, 95% CI 1.5 to 6.0), and moderate or severe heart failure (OR 2.5, 95% CI 1.2 to 5.2) as independent risk factors for death. There was a trend toward increased in-hospital mortality in patients with aortocavitary fistulae (OR 1.5, 95% CI 0.7 to 3.0). The actuarial 5-year survival rate in surgical survivors was 80% in patients with fistulae and 92% in patients with nonruptured abscesses (log-rank p = 0.6). In conclusion, aortocavitary fistulous tract formation in the setting of native valve IE is associated with higher rates of heart failure, ventricular septal defect, and atrioventricular block than nonruptured abscess. Despite these higher rates of complications, fistulous tract formation in the current era of IE is not an independent risk factor for mortality.

Infections due to Coxiella burnetii, the causative agent of Q fever, are uncommon in the United States. Cases of chronic Q fever are extremely rare and most often manifest as culture-negative endocarditis in patients with underlying valvular heart disease. We describe a 31-year-old farmer from West Virginia with a history of congenital heart disease and recurrent fevers for 14 months who was diagnosed with Q fever endocarditis based on an extremely high antibody titer against Coxiella burnetii phase I antigen. Despite treatment with doxycycline, he continued to have markedly elevated Coxiella burnetii phase I antibody titers for 10 years after the initial diagnosis. To our knowledge, this case represents the longest follow-up period for a patient with chronic Q fever in the United States. We review all cases of chronic Q fever reported in the United States and discuss important issues pertaining to epidemiology, diagnosis, and management of this disease.

Given that Lactobacillus has been reported to be the causative pathogen in many types of infection despite debate regarding the organism's clinical significance, a literature review was conducted to investigate the treatments and outcomes of Lactobacillus infections reported to date. In this article, the characteristics of over 200 reported cases of Lactobacillus-associated infections are summarized. Lactobacillus was found to be frequently associated with endocarditis and bacteremia. Lactobacillus was also associated with a variety of other infections including, but not limited to, peritonitis, abscesses, and meningitis. The species casei and rhamnosus were the most common. The isolates tended to be most sensitive to erythromycin and clindamycin and most resistant to vancomycin. The species that was most sensitive to vancomycin was acidophilus. The overall mortality rate was nearly 30%. There was a significant association between mortality and polymicrobial infection (P=0.004). In the subset of patients with bacteremia, increased mortality was associated with inadequate treatment (P=0.001) and polymicrobial bacteremia (P=0.044).

Background: Although cardiac devices have been found to reduce symptoms and mortality rates in appropriate patient populations, the implications of certain important risks, such as infection, are incompletely understood. The purpose of this study was to use a large population-based database to define the population that is at risk for cardiac device infections, determine the prevalence of device infections, and study changes in the rates of cardiac device implantation and infection in the past decade., Methods: Patients with cardiac device implantations and infections were identified with claims files from the Health Care Finance Administration for Medicare beneficiaries from January 1, 1990, through December 31, 1999. Rates of implantation of cardiac devices were determined. Time trend analyses were performed to determine the significance of the observed change in rates., Results: Cardiac device implantation rates increased from 3.26 implantations per 1000 beneficiaries in 1990 to 4.64 implantations per 1000 beneficiaries in 1999, which represents an increase of 42% in 10 years (P for trend <.001). Cardiac device infections showed a larger increase, from 0.94 device infections per 1000 beneficiaries in 1990 to 2.11 device infections per 1000 beneficiaries in 1999, which represents an increase of 124% during the study period (P for trend <.001)., Conclusions: During the previous decade, there was a significant increase in both cardiac device implantations and infections in elderly patients, although the increase in the rates of device infections was substantially higher. Additional studies are needed to better understand the relationship and timing between cardiac device implantation and infection.

Staphylococcus aureus is a leading cause of bacteremia and endocarditis. Over the past several years, the frequency of S aureus bacteremia (SAB) has increased dramatically. This increasing frequency, coupled with increasing rates of antibiotic resistance, has renewed interest in this serious, common infection. S aureus is a unique pathogen because of its virulent properties, its protean manifestations, and its ability to cause endocarditis on architecturally normal cardiac valves. Although the possibility of underlying endocarditis arises in virtually every patient with SAB, only a minority of bacteremic patients will actually have cardiac involvement. Distinguishing patients with S aureus infective endocarditis (IE) from those with uncomplicated SAB is essential, but often difficult. In this review, the authors summarize recent changes in the epidemiology of SAB and IE, discuss the challenges in distinguishing SAB from IE, and discuss current trends in the management of patients with SAB and IE.

Purpose: The national rate of and risk factors for bacterial endocarditis in renal transplant recipients has not been reported., Methods: Retrospective registry study of 33,479 renal transplant recipients in the United States Renal Data System (USRDS) between 1 July 1994 and 30 June 1997. Hospitalizations for a primary diagnosis of bacterial endocarditis (ICD-9 codes 421.x) within three years after renal transplant were assessed., Results: Renal transplant recipients had an unadjusted incidence ratio for endocarditis of 7.84 (95% confidence interval 4.72-13.25) in 1996. In multivariate analysis, a history of hospitalization for valvular heart disease (adjusted odds ratio (AOR), 25.81, 95% confidence interval 11.28-59.07), graft loss (AOR, 2.81, 95% CI 1.34-5.09), and increased duration of dialysis prior to transplantation were independently associated with hospitalizations for bacterial endocarditis after transplantation. Hospitalization for endocarditis was associated with increased patient mortality in Cox Regression analysis, hazard ratio 4.79, 95% CI 2.97-6.76., Conclusions: The overall incidence of bacterial endocarditis was much greater in renal transplant recipients than in the general population, although it is still relatively infrequent. Independent risk factors for bacterial endocarditis in the renal transplant recipients were identified, the most significant of which was valvular heart disease. Endocarditis substantially impacts renal transplant recipient survival.

Infective endocarditis (IE) is a serious disease that is associated with dental diseases and treatment. The objective of this study was to summarize the epidemiological information about IE and reevaluate previous causal models in light of this evidence. The world biomedical literature was searched from 1930 to 1996 for descriptive and analytic epidemiological studies of IE. Multiple searching strategies were performed on 9 databases, including MEDLINE, CATLINE, and WORLDCAT. Results show that: 1) the incidence of IE varies between 0.70 to 6.8 per 100,000 person-years: 2) the incidence of IE increases 20 fold with advancing age: 3) over 50% of all IE cases are not associated with either an obvious procedural or infectious event 3 months prior to developing symptoms; 4) about 8% of all IE cases are associated with periodontal or dental disease without a dental procedure: 5) the time from the diagnosis of heart valve deformities to the development of IE approaches 20 years: 6) the median time from identifiable procedures to the onset of IE symptoms is about 2 to 4 weeks: 7) the risk of IE after a dental procedure is probably in the range of 1 per 3,000 to 5,000 procedures: and 8) over 80% of all IE cases are acquired in the community, and the bacteria are part of the host's endogenous flora. The synthesis of these data demonstrates that IE is a disorder with the epidemiological picture of a chronic disease such as cancer, instead of an acute infectious disease, with a long latent period and possibly several definable intermediates or stages. A new causal model is proposed that includes early bacteremias that may "prime" the endothelial surface of the heart valves over many years, and a late bacteremia over days to weeks that allows adherence and colonization of the valve, resulting in the characteristic fulminant infection.

In the postantibiotic era, systemic complications from a gonococcal infection are rare. Females tend to have a higher frequency of gonococcal sepsis than males. In contrast, males have a higher rate of gonococcal endocarditis. This article describes a case of a previously healthy young male who presented with aortic insufficiency and blood cultures positive for Neisseria gonorrhoeae. Despite adequate antibiotic coverage, the patient's aortic insufficiency worsened, requiring aortic value replacement before discharge from the hospital. The patient's recovery was uneventful.