Community-acquired multidrug-resistant pneumonia,bacteraemia,and infective endocarditis:A case report

BACKGROUND The prevalence of multidrug-resistant(MDR)bacteria has increased globally,with extensive drug-resistant(XDR)bacteria posing a threat to patients.CASE SUMMARY This case report describes a young man admitted for suspected tropical fever infections who experienced rapid deterioration in health.Despite negative results for tropical fever infections,he had neutrophilic leucocytosis,acute kidney injury,and chest imaging findings suggestive of bilateral consolidations.On day two,he was diagnosed with infective endocarditis with possible rheumatic heart disease and MDR methicillin-resistant Staphylococcus aureus bacteraemia,and communityacquired pneumonia.Despite treatment with broad-spectrum antibiotics,he did not respond and succumbed to death on day five.CONCLUSION This case highlights that clinicians/public should be aware of MDR communityacquired pneumonia,bacteraemia,and endocarditis which ultimately culminate in high rates of morbidity and mortality.Early identification of pathogenic strain and prompt antibiotic treatment are a mainstay for the management and prevention of early fatalities.Simultaneously,route cause analysis of communityacquired MDR/XDR pathogens is a global need.

Infective Endocarditis in Chronic Hemodialysis Patients: Specificities and Therapeutic Management

Infective endocarditis (IE) is a frequent complication in chronic hemodialysis patients (CHD). The repeated placement and manipulation of central venous catheters, underlying valvulopathies, and immunosuppression are the main predisposing factors for these patients to develop IE. We aimed to highlight the clinical and microbiological specificities of IE in CHD patients, detail the therapeutic management in these patients and identify the risk factors for in-hospital mortality. We included 28 CHD patients in whom the diagnosis of IE was established according to modified Duke criteria. The mean age was 47 ± 17 years. Among them, 57% were hypertensive and 39% were diabetic. The average duration of hemodialysis was 3.5 ± 7 years. The vascular access was a tunnelled jugular catheter, arteriovenous fistula, and temporary catheter in 54%, 28%, and 18% of patients, respectively. Half of the patients presented with heart failure at admission. Methicillin-sensitive Staphylococcus is the most commonly implicated pathogen. Transthoracic echocardiography revealed vegetation in all patients. In 60% of cases, the lesion is located on the mitral valve, and in 35% it is on the tricuspid valve. Patients initially received empirical antibiotic therapy, which was adjusted according to bacteriological results. Valve surgery was indicated in 12 patients, with aortic valve replacement being the most performed procedure followed by tricuspid annuloplasty. The in-hospital mortality rate was 32%. Factors associated with mortality were severe mitral insufficiency (p = 0.036), heart failure (p = 0.043), and the presence of Methicillin-resistant Staphylococcus in blood cultures (p = 0.047). IE is a complication with high morbidity and mortality. Its increasing incidence, specificities in chronic CHD patients, and the complexity of its management require a rigorous preventive strategy. A multidisciplinary collaboration between nephrologists, infectious disease specialists, cardiologists, and surgeons is crucial to optimize therapeutic management.

Valve repair after infective endocarditis secondary to perforation caused by Streptococcus gordonii:A case report

BACKGROUND We report a case of infective endocarditis(IE)in a patient with congenital heart valve lesions accompanied by IE,which was diagnosed based on blood culture analysis that revealed the presence of a gram-negative bacterium,Streptococcus gordonii.CASE SUMMARY The patient had a history of precordial valve disease diagnosed by cardiac ultrasound,as well as a 4-mo history of fever.He was subjected to comprehensive anti-infection and anti-heart failure treatment in the internal medicine department.Further examination revealed sudden dislodgement from and perforation through the aortic valve by the superfluous organisms,as well as occurrence of bacterial emboli dislodgement,which caused bacteremia and infectious shock.He recovered and was discharged from the hospital after surgical and postoperative anti-infection treatments.CONCLUSION We review the treatment process and highlight inspirations and reflections from this case;suggest possible future changes in treatment modalities.

Clinical outcomes in patients with native valve infective endocarditis and diabetes mellitus

BACKGROUND There is a lack of data on the clinical outcomes in patients with native valve infective endocarditis(NVIE)and diabetes mellitus(DM).AIM To investigate(1)trends in the prevalence of DM among patients with NVIE;and(2)the impact of DM on NVIE outcomes.METHODS We identified 76385 with NVIE from the 2004 to 2014 National Inpatient Sample,of which 22284(28%)had DM.We assessed trends in DM from 2004 to 2014 using the Cochrane Armitage test.We compared baseline comorbidities,microorganisms,and in-patients procedures between those with vs without DM.Propensity match analysis and multivariate logistic regression were used to investigate study outcomes in in-hospital mortality,stroke,acute heart failure,cardiogenic shock,septic shock,and atrioventricular block.RESULTS Crude rates of DM increased from in 22%in 2004 to 30%in 2014.There were significant differences in demographics,comorbidities and NVIE risk factors between the two groups.Staphylococcus aureus was the most common organism identified with higher rates in patients with DM(33.1%vs 35.6%;P<0.0001).After propensity matching,in-hospital mortality(11.1%vs 11.9%;P<0.0001),stroke(2.3%vs 3.0%;P<0.0001),acute heart failure(4.6%vs 6.5%;P=0.001),cardiogenic shock(1.5%vs 1.9%;P<0.0001),septic shock(7.2%vs 9.6%;P<0.0001),and atrioventricular block(1.5%vs 2.4%;P<0.0001),were significantly higher in patients with DM.Independent predictors of mortality in NVIE patients with DM include hemodialysis,congestive heart failure,atrial fibrillation,staphylococcus aureus,and older age.CONCLUSION There is an increasing prevalence of DM in NVIE and it is associated with poorer outcomes.Further studies are crucial to identify the clinical,and sociodemographic contributors to this trend and develop strategies to mitigate its attendant risk.

Infective endocarditis and thoracic aortic disease: A review on forgotten psychological aspects

AIM To summarize the current evidence on psychological issues in thoracic aortic disease(TAD) and infective endocarditis(IE) setting. METHODS We performed a narrative review about psychological issues in adults with IE and TAD. Through the electronic databases, Pub Med and Psyc INFO, we searched full manuscripts in English and published until September 1, 2014. RESULTS We found sixteen studies exploring psychological issues in patients with IE(six studies) and in TAD(ten papers). Psychological issues assessed were quality of life, depression, anxiety and posttraumatic stress disorder. Quality of life was explored in IE(four papers) and in TAD(eight papers). Depression and anxiety were analyzed in TAD only(five papers). Post-traumatic stress disorder was assessed in IE(one study). Quality of life was found impaired in three of four studies about IE and in three of eight studies about TAD. Posttraumatic stress disorder was present in 11% and was associated with lower levels of quality of life in IE patients. In TAD patients, anxiety and depression levels after different invasive interventions did not differ. CONCLUSION Sixteen studies report about psychological issues in IE and TAD. Most of them explore quality of life and to a less extent anxiety and depression.

Diagnosis and Treatment of Infective Endocarditis in Chronic Hemodialysis Patients

Objective To analyze the clinical features of hemodialysis patients complicated by infective endo carditis. Methods The clinical features of six such patients admitted to Peking Union Medical College Hospital during the year 1990 to 2009 were analyzed. All of them were diagnosed based on Chinese Children Diagnostic Criteria for Infective Endocarditis. Results The average age of the six patients was 52.3±19.3 years old. Four were males. Vascular accesses at the onset of infective endocarditis were as follows： permanent catheters in three, temporary catheters in two, and arteriovenous fistula in one. Three were fbund with mitral valve involvement, two with aor tic valve involvement, and one with both. Five vegetations were found by transthoracic echocardiography, and one by transesophageal echocardiography. Four had positive blood culture results. The catheters were all removed. Four of the patients were improved by antibiotics treatment, in which two were still on hemodialy sis in the following 14-24 months and the other two were lost to follow-up. One patient received surgery, but died of heart failure alter further hemodialysis for three months. One was well on maintenance hemodi alvsis for three months after surgery. Conclusions Infective endocarditis should be suspected when hemodialysis patients suffer from long-term fever, for which prompt blood culture and transthoracic echocardiography confirmation could be performed. Transesophageal echocardiography could be considered even when transthoracic echocardiography produces negative findings. With catheters removed, lull course of appropriate sensitive antibiotics and surgery if indicated could improve the outcome of chronic hemodialysis patients complicated by infective cndocarditis.

Acquired aortocameral fistula occurring late after infective endocarditis: An emblematic case and review of 38 reported cases

AIM To delineate the features and current therapeutic option of congenital and acquired aortocameral fistulas(ACF) secondary to iatrogenic or infectious disorders.METHODS From a Pub Med search using the term "aortocameral fistula", 30 suitable papers for the current review were retrieved. Reviews, case series and case reports published in English were considered. Abstracts and reports from scientific meetings were not included. A total of 38 reviewed subjects were collected and analyzed. In addition, another case- an adult male who presented with ACF between commissures of the right and noncoronary sinuses and right atrium as a late complication of Staphylococcus aureus infective endocarditis of the AV- is added, the world literature is briefly reviewed.RESULTS A total of thirty-eight subjects producing 39 fistulas were reviewed, analyzed and stratified into either congenital(47%) or acquired(53%) according to their etiology. Of all subjects, 11% were asymptomatic and 89% were symptomatic with dyspnea(21 ×) as the most common presentation. Diagnosis was established by a multidiagnostic approach in 23(60%), single method in 14(37%)(echocardiography in 12 and catheterization in 2), and at autopsy in 2(3%) of the subjects. Treatment options included percutaneous transcatheter closure in 12(30%) with the deployment of the Amplatzer duct or septal occluder and Gianturco coil and surgical correction in 24(63%). CONCLUSION Acquired ACF is an infrequent entity which may occur late after an episode of endocarditis of the native AV. The management of ACF is generally by surgical correction but non-surgical device intervention has recently been introduced as a safe alternative.

Global and Regional Trends and Projections of Infective Endocarditis-Associated Disease Burden and Attributable Risk Factors from 1990 to 2030

Objective To forecast the future burden and its attributable risk factors of infective endocarditis(IE).Methods We analyzed the disease burden of IE and its risk factors from 1990 to 2019 using the Global Burden of Disease 2019 database and projected the disease burden from 2020 to 2030 using a Bayesian age-period-cohort model.Results By 2030,the incidence of IE will increase uncontrollably on a global scale,with developed countries having the largest number of cases and developing countries experiencing the fastest growth.The affected population will be predominantly males,but the gender gap will narrow.The elderly in high-income countries will bear the greatest burden,with a gradual shift to middle-income countries.The incidence of IE in countries with middle/high-middle social-demographic indicators(SDI) will surpass that of high SDI countries.In China,the incidence rate and the number of IE will reach 18.07 per 100,000 and 451,596 in 2030,respectively.IEassociated deaths and heart failure will continue to impose a significant burden on society,the burden on women will increase and surpass that on men,and the elderly in high-SDI countries will bear the heaviest burden.High systolic blood pressure has become the primary risk factor for IE-related death.Conclusions This study provides comprehensive analyses of the disease burden and risk factors of IE worldwide over the next decade.The IE-associated incidence will increase in the future and the death and heart failure burden will not be appropriately controlled.Gender,age,regional,and country heterogeneity should be taken seriously to facilitate in making effective strategies for lowering the IE disease burden.

Analysis of sleep characteristics and clinical outcomes of 139 adult patients with infective endocarditis after surgery

BACKGROUND Little is known about the postoperative sleep quality of infective endocarditis patients during hospitalization and after discharge.AIM To investigate the sleep characteristics of infective endocarditis patients and to identify potential risk factors for disturbed sleep quality after surgery.METHODS The Pittsburgh Sleep Quality Index(PSQI)and the Epworth Sleepiness Scale were used to assess patient sleep quality.Logistic regression was used to explore the potential risk factors.RESULTS The study population(n=139)had an average age of 43.40±14.56 years,and 67.6%were men(n=94).Disturbed sleep quality was observed in 86 patients(61.9%)during hospitalization and remained in 46 patients(33.1%)at 6 mo after surgery.However,both PSQI and Epworth Sleepiness Scale scores showed significant improvements at 6 mo(P<0.001 and P=0.001,respectively).Multivariable logistic regression analysis showed that the potential risk factors were age(odds ratio=1.125,95%confidence interval:1.068-1.186)and PSQI assessed during hospitalization(odds ratio=1.759,95%confidence interval:1.436-2.155).The same analysis in patients with PSQI≥8 during hospitalization suggested that not using sleep medication(odds ratio=15.893,95%confidence interval:2.385-105.889)may be another risk factor.CONCLUSION The incidence of disturbed sleep after infective endocarditis surgery is high.However,the situation improves significantly over time.Age and early postoperative high PSQI score are risk factors for disturbed sleep quality at 6 mo after surgery.

Effect of Ilizarov external fixation combined with negative pressure sealing drainage and antibiotics in the treatment of infective tibial nonunion

Objective:Observation on the effect of Ilizarov external fixation combined with vacuum pressure sealing drainage and antibiotics in the treatment of infective tibial nonunion.Methods:79 patients with tibial infective nonunion who were treated in our hospital from August 2016 to August 2018 were divided into two groups according to random number table,with 39 patients in the control group treated with Ilizarov external fixation technology and 40 patients in the study group treated with vacuum pressure sealing drainage and antibiotics on the basis of the control group.Bone healing time and daily walking were recorded.Rasmussen score,serum intercellular adhesion molecule-1(ICAM-1)and IL-6 levels,lower limb Fugl-Meyer motor function score and lower limb BI index score were compared at different time.Results:The daily walking condition of the study group was significantly better than that of the control group(P<0.05),and the healing time of bone was significantly shorter than that of the control group(P<0.05);the Rasmussen score of the study group was higher than that of the control group at 1 month,6 months and 12 months after treatment(P<0.05);the levels of serum ICAM-1 and IL-6 in the two groups after treatment were lower than those before treatment(P<0.05),and the levels of serum ICAM-1 and IL-6 in the study group were lower than those in the control group after treatment(P<0.05).The lower limb Fugl-Meyer motor function score and lower limb BI index score of the two groups after treatment were higher than those before treatment(P<0.05),and the lower limb Fugl-Meyer motor function score and lower limb BI index score of the study group after treatment were higher than those of the control group(P<0.05).Conclusions:Ilizarov external fixation combined with vacuum pressure sealing drainage and antibiotics can promote the bone healing of patients with infective tibial nonunion,significantly improving their daily walking condition,alleviating inflammation,and recovering the knee joint function and lower limb function well.

Infective endocarditis as a rare cause for acute limb ischemia

Infective endocarditis （IE） occurs at a rate of approximately 1-7/100 000 people per year, and has a high morbidity and mortality despite advances in antibiotic and surgical treatments.

A Case of Comorbidity of Complicated Infective Endocarditis and Severe Pneumonia Due to Legionella Pneumophila

Legionella pneumophila infection can cause Legionnaires’disease,a severe form of pneumonia.Extrapulmonary manifestations of Legionella infections include myocarditis,pericarditis,and endocarditis.We present a rare case of pneumonia caused by Legionella pneumophila with a possible etiologic link to a recently recovered culture-negative infective endocarditis.

Infective myositis A one-case report

BACKGROUND： Infective myositis is rare. The retrospective report of clinical data and symptoms from one patient with infective myositis will hopefully provide more information for clinicians in the diagnosis of this disease. METHODS： A male patient, 65 years old, was admitted with ＂fever and muscle pain since four days ago, accompanied by inertia of all limbs for one day＂, to the First Department of Neurology, Guangdong Provincial Hospital of Traditional Chinese Medicine on April 25th, 2005. Following admission, a history of diseases was record, and detailed physical and neurological examinations were performed. During the examination, symmetrical myasthenia appeared, tendon reflex disappeared, and creatine kinase levels were increased 500 times higher than normal. The patient was primarily diagnosed with hypokalemic periodic paralysis, myositis, Guillain-Barre syndrome, and upper respiratory infection. Subsequently, the patient was treated with the following： cefuroxime for infection, potassium supplements, breviscapin for promoting blood circulation through the removal of stasis, and ATP/CO-A for myocardial nutrition. Antiviral drugs were not administered. However, laboratory samples were continuously monitored. Creatine kinase levels decreased to normal, and muscle pain was obviously relieved following antibiotics treatment. The results led to a final diagnosis of infective myositis. RESULTS： Four days after treatment （April 29th）, muscular tenderness and throat congestion were obviously improved （＋/-）. The neurological examination showed the patient was conscious, cooperated with treatment, and had normal intellect. No abnormalities of the cranial nerve were observed upon examination. Proximal and distal muscle strength and muscular tensions of the four limbs were all normal. Reflexes of the right biceps brachii muscle and its tendon were decreased, and knee tendon and Achilles tendon reflex were not induced. A Babinski reflex was not detected. The neurological examination presented no abnormalities, and the related creatine kinases were within normal range by re-examination at 2 weeks, and l and 3 months after discharge. CONCLUSION： A diagnosis of infective myositis should be considered for patients with clear prodromes of infection, that include symptoms of periodic paralysis and elevated creatine kinase levels. Treatment with sufficient antibiotics can obtain good results.

Aorto-right atrial fistula: Late complication of tricuspid valve infective endocarditis

Abnormal connections between the ascending aortaand the cardiac chambers are rare, especially in thecontext of right-sided infective endocarditis(IE). Trans-thoracic echocardiography(TTE) with color-flow Dop-pler, transesophageal echocardiography(TEE), or bothmay be required for diagnosis. We present the case ofa woman admitted with right-sided heart failure(HF)symptoms. She had a previous history of tricuspid valveIE 30 years ago. TTE and TEE revealed an aorto-rightatrium fistula located just under the non-coronary cuspinto the right atrium at the level of the previously af-fected tricuspid valve. The Patient refused surgery andwas discharged home on HF medications. She has beenstable for the last 3 years. The peculiarity of this caseis the late symptomatic presentation of the aorto-atrialfistula and the unusual association to tricuspid valve IE.

Gram-negative bacteria causing infective endocarditis: Rare cardiac complication after liver transplantation

Bacterial endocarditis is a rare complication amongst solid organ transplant recipients and is often linked to bacteremia. Majority of these recipients do not have underlying valvular heart disease or congenital valvular abnormalities. Staphylococoocusaureus and Enterococcus species are the most commonly isolated organisms. There are very few reports of gram-negative bacteria causing endocarditis in liver transplant recipients. We report a 51-yearold male, a liver transplant recipient, who developed bacterial endocarditis of the mitral valve due to extended spectrum of betalactamase producing strain of Escherichia coli and was managed successfully with antibiotics.

A Rare Case of Infective Mediastinitis after Melody Valve Implantation

Pulmonary valve implant is frequently necessary in children and adults with congenital heart disease.Infective endocarditis represents a rare but life-threatening complication after transcatheter pulmonary valve implantation.There are various treatments for native or prosthetic valve endocarditis.Surgical intervention,combined with intravenous antibiotic treatment,is of paramount importance,in case of concomitant mediastinal infection,in order to ensure the radical debridement of all infected tissue,avoiding any recurrent endocarditis.In this report,we describe a rare case of mediastinitis,associated with an infected endocarditis,occurring 8 months after Melody(Medtronic
,Minneapolis,USA)valve implant,successfully treated with the implantation of a homograft to reconstruct the right ventricular outflow tract.

Leclercia adecarboxylata infective endocarditis in a man with mitral stenosis:A case report and review of the literature

BACKGROUND Infective endocarditis(IE) is a rare disease with a high mortality rate.Leclercia adecarboxylata(L.adecarboxylata) is a movable Gram-negative bacillus of enterobacteriaceae,and it can rarely be a pathogen which often affects immunodeficient patients.There are about three cases of immunocompetent patients with monomicrobial L.adecarboxylata infection.There are only three reported cases of IE caused by L.adecarboxylata in the world.The mitral valve is often affected in IE,and the prognosis for IE with mitral valve lesions is often poor.CASE SUMMARY A 51-year-old man was found to have moderate to severe mitral stenosis on echocardiography.He came to our Cardiothoracic Surgery Department for surgical management.A diastolic murmur was heard on auscultation of the heart in the mitral region.On the second day of hospitalisation,he presented with slurred speech,reduced muscle strength in the left limb,and acute cerebral infarction on cranial computed tomography.Surgical treatment was decided to postpone.On the ninth day of admission,the patient developed a sudden high fever and shock and was transferred to the Cardiac Intensive Care Unit,where echocardiogram revealed an anterior mitral valve leaflet vegetation.After empirical anti-infective treatment with vancomycin(1g q12h),an emergency valve replacement was performed.Bacterial culture identified L.adecarboxylata.Antiinfective treatment with piperacillin-tazobactam(4.5g q8h) was added for 4 wk.Follow-up echocardiography showed normal bioprosthetic valve function after mitral valve replacement.CONCLUSION We report the first case of L.adecarboxylata IE in China,and clinicians should pay attention to this pathogen.

Immediate and Long-Term Results of Transcatheter Closure of Patent Ductus Arteriosus—Comparison of Two Decades before and after Change in Antibiotic Infective Endocarditis Prophylaxis Guidelines

Objectives:To determine immediate and long-term follow-up of transcatheter closure of patent ductus arteriosus(PDA)in children.Background:National antibiotic prophylaxis(AP)guideline for infective endocarditis changed after 2009,the effect on practice of PDA closure is unknown.Methods:Observational single center study analyzing follow-up of PDA closure comparing two time periods before(2002–2009)and after(2010–2019)changes in AP guideline.Results:332 patients(68.1%female),median(interquartile range)age 3.0 years(1.5–5.7)and body weight 14.0 kg(10.0–19.3),were enrolled.PDA morphology was conical type A(50.3%),window type B(1.2%),tubular type C(40.1%),complex type D(2.1%),elongated type E(0.9%)and other(5.4%).Minimal PDA diameter and length were 1.9 mm(1.3–2.5)and 8.0 mm(6.2–10.2).PDA was closed using coils(56.3%),Amplatzer Duct Occluders(41.9%)and others(1.8%).Complete closure rate was 61.1%at catheter intervention,72.3%on day 1,87.7%after 6 months and 98.4%at last follow-up on echocardiography.Moderate complication rate(severity level 3)was 4.2%and major complication rate(severity level 4)0.3%,with no catastrophic complications(severity level 5).Annual PDA closure rate declined in the second time period(22.6/year vs.15.5/year,p=0.018),PDA size increased(1.6 mm vs.2.0 mm,p=0.002)and proportion of coils decreased(72.4%vs.37.1%,p<0.001).Conclusions:Interventional closure of PDA is associated with excellent closure rates during follow-up(>98%)and only a small number of complications leading to reintervention or surgery.Change in AP guidelines changed indication for and practice of PDA closure.

Neocuspidization of the Pulmonary Valve with Autologous Pericardium in the Adult Patient with Ventricular Septal Defect and Infective Endocarditis: A Case Report and Review of the Literature

Congenital heart disease (CHD) is one of the risk factors for developing infective endocarditis (IE). Right-sided IEoccurs in 5%–10% of endocarditis cases, and pulmonary valve (PV) is involved in less than 2% of such patients.Literature data are few, and optimal treatment methods, indications for surgery, and types of operative techniquesare still under debate. We present an adult patient with a rare combination of the ventricular septal defect (VSD)and PV IE who underwent surgical treatment. Neocuspidization with autologous pericardium was utilized for thereconstruction of his PV. We discuss details of this novel surgical technique.

Infective bicuspid aortic valve endocarditis causing acute severe regurgitation and heart failure:A case report

BACKGROUND Infective endocarditis(IE)is an uncommon but potentially life-threatening infection,which occasionally develops into acute severe valve insufficiency leading to the onset of heart failure,and necessitates timely intervention.However,the variable and atypical clinical manifestations always make the early detection of IE difficult and challenging.CASE SUMMARY A 45-year-old female who was previously healthy presented with exertional shortness of breath and paroxysmal nocturnal dyspnea.She also suffered from a significant decrease in exercise capacity,whereas her body temperature was normal.She had severe hypoxemia and hypotension along with a marked aortic valve murmur.Diffuse pulmonary edema and bilateral pleural effusion were observed on both chest X-ray and computed tomography scan.Transthoracic echocardiography was performed immediately and revealed severe regurgitation of the bicuspid aortic valve.Transesophageal echocardiography was further performed and vegetations were detected.In addition to adequate medical therapy and ventilation support,the patient underwent urgent and successful aortic valve replacement.Her symptoms were significantly relieved and the postoperative chest X-ray showed that pulmonary edema was significantly reduced.Histopathology of the resected valve and positive microorganism culture of the surgical specimen provided evidence of definite IE.CONCLUSION IE should be considered in critical patients with refractory heart failure caused by severe bicuspid aortic valve regurgitation.