Infective Endocarditis

Background: The objective of this study was to analyse the impact of acute surgery for native aortic valve endocarditis and its influence on the long-term prognosis after surgery. Methods: A total of 161 patients underwent aortic valve replacement for native active aortic valve endocarditis (NAAVE) during a 29-year period, from 1967 to 1995 (age range: 10 to 72 years; mean 48 ± 12). The main indication for surgery was progressive congestive heart failure (76%). Other indications were unbeatable sepsis (27%), peripheral or central emboli (12%) and, from 1978, echocardiographic evidence of friable, pedunculated vegetations (3%). Streptococcal and staphylococcal infections predominated. Concomitant procedures were performed in 27% of the patients, including mitral and tricuspid valve surgery and coronary bypass procedures. Results: Operative mortality was 8% in the majority of cases caused by heart failure or multiorgan failure. Multivariate logistic regression analysis identified NYHA class IV to be an independent predictor for postoperative death. Long-term survival for discharged patients was 75% at 10 years and 58% at 15 years, with a mortality rate of 3.6%/patient/year. Cox regression analysis identified the year of operation, trivalvular endocarditis and staphylococcal infection as independent predictors of survival. At 10 and 15 years after aortic valve replacement, 91% and 84% of the patients, respectively, were free of recurrent endocarditis. The presence of an abscess cavity at first operation was found to be predictive of recurrent endocarditis. Conclusions: Valve replacement for NAAVE offers a good chance for a cure and satisfactory long-term survival. Improvements in pre- and per-op-rative management of the very ill patient, and the use of allograft valves are likely to further improve long-term results. Finally, the presence of staphylococcal endocarditis requires long-term postoperative antibiotic therapy.

Background: Early prosthetic valve endocarditis is a serious life threatening infection of newly implanted prosthetic heart valve. A positive post-surgery heart valve culture is a significant risk factor for development of early prosthetic valve endocarditis.

Background. There are advantages to using homografts and autografts as aortic valve replacements, particularly in patients with infective endocarditis. To better define these advantages, we reviewed our 13-year experience with the surgical management of infective endocarditis involving the aortic valve and root.

Slow-growing bacteria and biofilms are notoriously tolerant to antibiotics. Oritavancin is a lipoglycopeptide with multiple mechanisms of action that contribute to its bactericidal action against exponentially growing gram-positive pathogens, including the inhibition of cell wall synthesis and perturbation of membrane barrier function. We sought to determine whether oritavancin could eradicate cells known to be tolerant to many antimicrobial agents, that is, stationary-phase and biofilm cultures of Staphylococcus aureus in vitro. Oritavancin exhibited concentration-dependent bactericidal activity against stationaryphase inocula of methicillin-susceptible S. aureus (MSSA) ATCC 29213, methicillin-resistant S. aureus (MRSA) ATCC 33591, and vancomycin-resistant S. aureus (VRSA) VRS5 inoculated into nutrient-depleted cation-adjusted Mueller-Hinton broth. As has been described for exponential-phase cells, oritavancin induced membrane depolarization, increased membrane permeability, and caused ultrastructural defects including a loss of nascent septal cross walls in stationary-phase MSSA. Furthermore, oritavancin sterilized biofilms of MSSA, MRSA, and VRSA at minimal biofilm eradication concentrations (MBECs) of between 0.5 and 8 g/ml. Importantly, MBECs for oritavancin were within 1 doubling dilution of their respective planktonic broth MICs, highlighting the potency of oritavancin against biofilms. These results demonstrate a significant activity of oritavancin against S. aureus in phases of growth that exhibit tolerance to other antimicrobial agents.

To prevent infective endocarditis (IE), Australian guidelines recommend providing prophylactic antibiotics to Indigenous patients with rheumatic heart disease (RHD) prior to procedures which may cause bacteremia. In northern Australia RHD remains prevalent. We aimed to determine whether RHD is associated with an increased risk of IE, which risk factors are associated with IE, and the incidence and aetiology of IE.

before it has a local effect on PV flow. Methods: Using an elaetanca model of the atrium and PV tree, Coraviously demonstrated to reliably reproduce PV flow), mitral regurgitation was simulated (regurgitant volume = 16 co). Using equa~ons from fluid mechanics that describe the spatial distribution of pressure recovery created as a jet impinges on a wall, the distance between the jet impact site and a given PV was varied from 4 to 0,5 cm and systolic PV flow was plotted. Results:WdllOut regurgitation, the model generated systolic PV flow consistent with clinical measurements, With regurgitation, systolic PV velocity was reduced. At 4 and 1 cm impingement distances, the effect was minimal, but at 0.75-0.5 cm, PV flow rapidly became diminished and rovemed.

Background. The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997. Methods and Results. A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) 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 IE. The recommendations in this document reflect analyses of relevant literature regarding procedurerelated bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, pre-

Spondylodiscitis is rarely observed in association with infective endocarditis (IE). In the study presented here, 92 cases of definite IE were examined. Spondylodiscitis was present in 14 (15%) cases. The mean age of patients with spondylodiscitis was 69.1±13.6 years (range, 33-87 years). The male-to-female ratio was 8:6. Predisposing heart disease was found in nine (64.3%) cases. Back pain was reported in all cases. Spondylodiscitis was diagnosed before endocarditis in all cases. The infection affected the lumbar spine in 10 (71%) cases. A bacterium was isolated in all cases: group D Streptococcus (n=5; 35.7%), coagulase-negative Staphylococcus (n=4; 28.6%), and others (n=5). Endocarditis affected predominantly the aortic valve (43%). The outcome was favourable in 12 cases. No differences in clinical features, evolution of disease, or laboratory values were found between IE patients with and IE patients without spondylodiscitis. Spondylodiscitis does not appear to worsen prognosis of IE, although the need for cardiac valve replacement seems to be more frequent in IE patients with spondylodiscitis. IE should be included in the differential diagnosis in patients with infectious spondylodiscitis and risk factors for endocarditis. In such patients, echocardiography should be performed routinely.

S. aureus infective endocarditis (SAIE) is a serious infection associated with considerable morbidity and mortality. There is evidence that the incidence of SAIE is increasing. As its clinical features are non-specific, SAIE must be suspected in every case of S. aureus bacteraemia, whether it is associated with an obvious source or not. The optimal antimicrobial agent(s) and duration of treatment for SAIE are currently not known, but on the basis of present evidence, a minimum of 2 weeks of antimicrobial therapy is recommended for 'right-sided' SAIE, a minimum of 4 weeks for uncomplicated 'left-sided' SAIE, and a minimum of 6 weeks for complicated 'leftsided' or prosthetic valve SAIE. Although there is no evidence to suggest that combination therapy with a cellwall active agent (e.g. flucloxacillin) and an aminoglycoside decreases mortality in SAIE, combination therapy should be considered during the initial 3-5 days of therapy as it can shorten the duration of bacteraemia. In complicated or prosthetic valve SAIE, early and close liaison with cardiology and cardiothoracic surgery services is essential. Rapid identification and susceptibility testing of the infecting organism are important in determining the choice of definitive antimicrobial therapy. (Intern Med J 2005; 35: S25-S44)

Background
Left Ventricular Outflow (LVOT) masses are rare and raise
concern for infective endocarditis vegetations, thrombus,
and cardiac tumors. When these masses arise in the LVOT,
they can lead to symptoms of LVOT obstruction and
thromboembolism. The most common cause of a cardiac
tumor is cardiac myxoma, occurring in 0.02% of the
population, and almost exclusively arises in the atria [1].
We present two cases of large cardiac masses of different
pathology arising in the left ventricle causing LVOT
obstruction.

Background. The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997. Methods and Results. A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) 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 IE. The recommendations in this document reflect analyses of relevant literature regarding procedurerelated bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, pre-

Defekti Gerbode eshte nje forme e rralle e defektit septal ventrikular, i cili  konsiston ne  nje komunikim midis ventrikulit te majte dhe atriumit te djathte. Ai është zakonisht kongenital, por mund te  prezantohet edhe si pasojë e Infarktit të Miokardit, traumave të kraharorit, ose si komplikacion i fituar pas ndërhyrjejeve të mëparshme kardio-kirurgjikale. Me rralle, ndodh edhe ne terren te Endokarditit Bakterial si pasoje e shkaterrimit te strukturave kardiake ne kushtet e nje infeksioni akut apo subakut. Kjo është anatomikisht e mundur sepse valvula normale trikuspidale gjendet e zhvendosur në raport me atë mitrale.
Ne do te paraqesim një rast të pacientit tonë me këtë komplikacion të pazakontë të endokarditit që simulonte nje hipertensioni pulmonar te rende. Ne dijenine tone, raste te tilla te Defektit Gerbode te fituar ne kushtet e nje  Endokarditi Bakterial jane shume te rralla, dhe ky eshte rasti i pare i botuar ne gjithe eksperiencen shqiptare.

Fjalë kyçe: defekti Gerbode; ekokardiografi torakale; endokarditi infektiv; atrium i djathte; hipertensioni arterial pulmonar

Bacterial endocarditis secondary to jet lesions from congenital heart disease is not uncommon, and has been reported on numerous occasions in the literature. These cases usually involve one or more cardiac valves. Our case is that of isolated intracardiac right-sided mural infective endocarditis associated with ventricular septal defect. Importantly, this patient had preceding dental work treated with antibiotic prophylaxis. This case highlights bacteraemia secondary to dental instrumentation versus routine oral hygiene. His presentation was predominantly that of respiratory symptoms and sepsis, and he was culture negative throughout his admission. The lesion was detailed on echocardiography and transoesophageal echocardiography, and treated conservatively. He has subsequently been referred for VSD closure. (T. Lin), [email protected] (M. Santos), [email protected] (C. Aboltins), [email protected] (H. Chiu), [email protected] (W. Van Gaal), [email protected] (C. Wong) 1 Fax: +61 8405 8405.

В представленном обзоре отмечено изменение эпидемиологического профиля инфекционного эндокардита (ИЭ) с увеличением заболеваемости в пожилом возрасте. Обсуждаются факторы риска ИЭ, включая перенесенные ранее заболевания эндокарда различного генеза, имплантацию искусственного клапана, проведение различных лечебных и диагностических инвазивных процедур и особенно кардиохирургических вмешательств. Среди факторов риска, предрасполагающих к инфекционному поражению эндокарда у пожилых лиц, отмечены кальцификация клапанов, возрастные изменения эндокарда, наличие сахарного диабета, воспалительных заболеваний желудочно-кишечного и урогенитального тракта. Приведены особенности этиологического спектра возбудителей ИЭ, характеризующиеся увеличением частоты случаев, вызванных S. bovis, энтерококками, коагулазонегативными стафилококками по сравнению с более молодыми группами больных. В обзоре особое внимание уделяется микробиологической диагностике, как одному из больших критериев в диагностике ИЭ. Подходы к лечению заболевания приведены с учетом общих принципов, выбора эмпирической терапии и назначения соответствующих антибактериальных препаратов после получения результатов бактериологического исследования гемокультуры. Принципы лечения пожилых больных с ИЭ основаны на рекомендациях экспертов Европейского Общества Кардиологов и Американской Ассоциации Сердца, опубликованных в 2015 г. Подчеркивается важность профилактики инфекционного поражения эндокарда у лиц высокого риска при применении манипуляций высокого риска, а также соблюдения общих гигиенических мер и санитарных норм.

Background: Linezolid is a bacteriostatic oxazolidinone antibiotic that has been proven to be effective for the treatment of patients with pneumonia, skin and soft tissue infections, and possibly bacteraemia, due to Gram-positive cocci. However, the drug is sometimes used for the treatment of patients with endocarditis due to Gram-positive cocci resistant to other antibiotics.

Objective: In the surgical treatment of acute aortic valve infective endocarditis (IE), the long-term outcome depending on the choice of valve replacement remains uncertain. We aimed to compare the impact on 5-year mortality of use of three types of implanted valves: bioprosthesis (heterograft), mechanical prosthesis and homograft. Methods: A total of 167 patients with a definite aortic valve IE who underwent aortic replacement were selected from a prospective observational population-based study. Association between the type of implanted valve and 5year mortality was examined by the use of an adjusted Cox model. Results: Bioprostheses were implanted in 31 patients (18.6%), homograft in 27 (16.2%) and mechanical valves in 109 (65.2%). Patients with bioprothesis had a higher 5-year mortality risk than patients with mechanical prosthesis (adjusted hazard ratio (HR) 2.39, 95% confidence interval (95% CI), 1.09-5.21; p = 0.029), particularly in patients 65 years old (adjusted HR 4.14 (1.27-13.45), p = 0.018) but not in patients >65 years old (adjusted HR: 1.45 (0.35-5.97), p = 0.60). Five-year mortality risk did not differ between patients with homografts and those with mechanical prostheses (HR 0.46, 95% CI (0.15-1.42), p = 0.18). Conclusions: A bioprosthetic valve used for aortic valve IE replacement may be associated with lower overall 5-year survival than the use of a mechanical valve in patients up to 65 years old. Further studies are needed to explain these results. #

SUMMARY Mitral valve prolapse (MVP) is a frequent echocardiographic diagnosis. The clinical evolution of patients with MVP is very variable. There are no national data about the clinical evolution of these patients. The aim of this report is to study the clinical evolution of patients with an echocardiographic diagnosis of MVP and to detect risk factors of a bad evolution.

We report 81 of 107 cases of hemolytic uremic syndrome (HUS), admitted between July 1994 and February 1996, following an outbreak of Shigella dysenteriae type 1 dysentery in Kwazulu/Natal. All patients, excluding 1, were black with a mean age of 38 months (range 1 -121); 50 (61.7%) were males. The mean duration of dysentery was 11.3 days (range 1 -41) and HUS 15 days (range 1 -91). Most patients had acute oliguric renal failure (90.1%); 42 (51.6%) required peritoneal dialysis. Complications included encephalopathy 30 (37.0%), convulsions 12 (14.8%) and hemiplegia 2 (2.3%), gastrointestinal perforation 8 (9.9%), protein losing enteropathy 26 (32.1%), toxic megacolon 4 (4.9%), rectal prolapse 5 (6.2%), hepatitis 11 (13.6%), myocarditis 5 (6.2%), congestive cardiac failure 3 (3.7%), cardiomyopathy 3 (3.7%), infective endocarditis 1 (1.2%), septicemia 15 (18.5%), disseminated intravascular coagulation 17 (21%). Leukemoid reactions were found in 74 (91.3%) patients, hyponatremia in 56 (69.1%), and hypoalbuminemia in 67 (82.7%). Stool culture for Shigella dysenteriae type I was positive in only 7 (8.6%) patients; Shiga toxin assays were not performed. Outcome was as follows: recovery 32 (39.5%), impaired renal function 8 (9.9%), chronic renal failure 26 (32.1%), end-stage renal disease 1 (1.2%), and death 14 (17.3%) patients.

0.4-1.1% of patients having permanent pacemaker implantation suffer serious infections leading to endocarditis. Generally accepted mode of therapy in these group of patients is removal of the infected pacemaker and lead that has caused endocarditis and accomplishing long term antibiotic therapy and accompanied by implantation of a new pacemaker to another anatomic site. A 71 year old female had implantation of permenant pacemaker 8 years ago owing to total AV block which was tended to be removed 1 year ago. However the lead was left in place because of the dense adherences and another pacemaker was introduced through left subclavian vein. Patient then addmited with signs and complaints of infection. Although the newly implanted pacemaker and lead was removed with suspected infection and ampiric antibiotherapy was initiated, clinical signs continued and ecocardiography revealed vegetation on the previously implanted lead. Surgical extraction of the lead was planned and preoperative angiography showed aterosclerotic leison in the circumflex artery. Infected lead was extracted by the use of cardiopulmonary bypass through right atriotomy incision with concommitant bypass and implantation of epicardial DDD-R pacemaker. Postoperative period was uneventful and patient was discharged on 15 th postoperative day without signs of infection.The pacemaker system must be removed in cases of endocarditis owing to the infected pacemaker lead. Simple transvenous extraction has to be avioded especially when the tip of the lead is infected. This method prevents the risk of pulmonary embolisation associated with vegetation and mechanic injury to the tricuspid valve and right ventricule

We report the case of acquired left ventricle (LV) to right atrial (RA) communication through an aneurysm of the atrioventricular septum caused by infectious endocarditis. A severe aortic valve regurgitation and destruction of the aortic valve was detected by echocardiography. Transesophageal echocardiography revealed a flail aortic valve with vegetation and abnormal shunt flow from the LV to RA with ruptured aneurysm of the membranous septum. An abscess cavity of the aortic ring was introduced. Because of worsening congestive heart failure, the patient underwent emergency aortic valve replacement and patch closure of the communication of the membranous septum. The patient's postoperative course was uneventful.

Background: Few population-based studies provide epidemiological data on infective endocarditis (IE). Aim of the study is to analyze incidence and outcomes of IE in the Veneto Region (North-Eastern Italy). Methods: Residents with a first hospitalization for IE in 2000-2008 were extracted from discharge data and linked to mortality records to estimate 365-days survival. Etiology was retrieved in subsets of this cohort by discharge codes and by linkage to a microbiological database. Risk factors for mortality were assessed through logistic regression. Results: 1,863 subjects were hospitalized for IE, with a corresponding crude rate of 4.4 per 100,000 person-years, increasing from 4.1 in 2000-2002 to 4.9 in 2006-2008 (p = 0.003). Median age was 68 years; 39% of subjects were hospitalized in the three preceding months. 23% of patients underwent a cardiac valve procedure in the index admission or in the following year. Inhospital mortality was 14% (19% including hospital transfers); 90-days and 365-days mortality rose through the study years. Mortality increased with age and the Charlson comorbidity index, in subjects with previous hospitalizations for heart failure, and (in the subcohort with microbiological data) in IE due to Staphylococci (40% of IE). Conclusions: The study demonstrates an increasing incidence and mortality for IE over the last decade. Analyses of electronic archives provide a region-wide picture of IE, overcoming referral biases affecting single clinic or multicentric studies, and therefore represent a first fundamental step to detect critical issues related to IE.

Then the attention was concentrated on the possible and more diffuse agents which may contaminate the food, the water and the environment and the possible methods which may be sufficient precise, rapid and easy to use on a large number of person and samples. Dr. Coenye elaborated a fast method consisting in solid-phase cytometry which permits to analyse many samples and gives the possibility to visualise few bacteria or other kind of cells also if they are in small number. The analysis was made on air samples, on water and food samples. As regards the water possible contamination of the source in relation to the particular structure of the soil was suggested by Vardanyan and Aginian. Then the study was divided in four sectors of possible contaminant: bacteria especially the more diffuse, virus, parasites and pollutants. Of each the possible way of diffusion, the consequent diseases and the more modern and safe methods used for diagnosis were presented and discussed in view of the results obtained. presence and also some chemical treatment can limit the development of these bacteria. The experiments therefore showed that the ham is practically safe as regard a possible contamination from this bacterium which is common in pig skin. The second section is dedicated to virus infection. Hepatitis B is taken in consideration for his consequence and since it is easy to diffuse not only through blood, but also through contaminated instruments, sexual contacts and to the infants from infected mother. The diagnosis is fundamental in order to prevent the diffusion, since the disease tends to be chronic and causes cirrhosis. Vaccination could prevent the illness. Another emergent viral hepatitis is that causes by E virus, a single stranded RNA virus, which is endemic in many areas like North America and Asia. It can be transmitted via the faecal-oral route, water and also food. This virus causes acute hepatitis and it is important to distinguish it from other kind of viral hepatitis. The pathogenesis of hepatitis E is not well known and the diagnosis is actually mainly serological even if a molecular method represents that preferable to be developed. Another emergent disease is due to Dengue viruses which may cause infections similar to a simple flu up to more severe syndromes like haemorrhagic fever or dengue shock syndrome. The genome of Dengue virus is formed by RNA of approximately 11 kb in length, composed by three structural genes and seven non structural protein. Since this virus does not give origin to a specific disease, it is necessary to make a precise diagnosis; at moment many methods exist, like immunological text and the authors in their article make a comparison between them. In the third section parasites have been taken in consideration an infection which can be transmitted mainly from food either vegetable or animal including fishes. A complete review of the possible parasites contamination and especially of some emerging or re-emerging ones is presented in the paper of Dei Cas and others. They first take in consideration the difference between the various geographical areas underlined the fact that these infections affect more than three millions of people in the area in which the people live with less than $2 per day. These infections are also responsible of mental and physical underdevelopment of Africa children. The most diffuse are Cryptosporidium and Giardia intestinalis which may be transmitted with the faeces of cat or domestic dog. Less diffuse but equally important for the pathological consequences are Trypanosoma cruzi and Toxoplasma gondii which are diffuse also in America and Europe. The presence of some parasites, like Diphyllibotrium, in fishes favours the contamination especially when are used not cooked such sushi or marinated fishes infected with larval plerocercoids. The diffusion is mainly in the freshwaters and in Europe especially in Switzerland and in Italian, French Alpine lake region. Schistosoma haematobium which seems responsible of urinary bladder carcinoma and S. japonicum and S. mansoni which are linked to hepatic and colorectal carcinoma. Since the way of diffusion is not well known a possible presence of parasites and the relative consequence may represent a risk. Biological pollutant are due to fungi toxic metabolites which can contaminate foods are known as micotoxins. These products are not necessary for the fungi growth and they can be present in the environment as well as in foods. Their effect on the human health depend not only by its characteristic, but also by the immune system of each person. A biosensor system is developed in order to evaluate contaminants in very simple and quick way. The results are compared with standard methods such as HPLC and ELISA. In conclusion, our analysis includes a large spectrum of diffuse contaminants which may spread mainly with foods and can be the causes of many pathologies some of them could be very severe. The development of quick and un-expensive new methods represent an help for diagnostic purposes since in many case it is necessary to analyse a large number of samples. The use of some of them to prevent bio-terrorist attack may interest a large number of people in the same time or may in some cases be responsible of chronic diseases with high mortality. It is easy to Part I Bioterrorism Prevention 3 M.V. Magni (ed.), Detection of Bacteria, Viruses, Parasites and Fungi,

55 eter (r=0.29, p=0.04), TP-Ea (r=0.37, p=0.004) and GLS (r=-0.57, p<0.0001). On multivariate analysis, after adjustment for age, sex and LV systolic diameter, only TP-Ea (r 2 =0.10, p=0.004) and GLS (r 2 =0.32, p<0.0001) were independently associated with BNP. Interestingly, for 1% decrease in GLS, BNP raise of 2.6pg/ml. In addition, GLS was an independent predictor of BNP ≥26pg/l (odds-ratio=1.3, 95%CI: 1.05-1.56, p=0.005).