Steckelberg, James M.

Device infection is associated with increased mortality in cardiovascular implantable electronic device (CIED) recipients. However, published data regarding clinical predictors of mortality in patients with CIED infection are limited. In current investigation, we sought to identify patient and device-related factors associated with mortality in CIED infection cases. We performed a retrospective review of all cases of CIED infection admitted to Mayo Clinic Rochester from 1991 to 2008. Survival data were obtained from hospital medical records and United Sates Social Security Index. Key data regarding patient demographics, device features, comorbid conditions, clinical presentation, echocardiographic findings and management strategies were abstracted. Potential risk factors for short (30-day) and long-term mortality were analyzed using univariate and multivariable logistic and Cox proportional hazards regression models, respectively. 415 cases of CIED infection were identified from the institutional database. The mean duration of follow-up for the 243 patients who were alive at last follow-up was 6.9 years. In multivariable model, congestive heart failure (CHF, Odds ratio 9.31, 95% CI 2.08-41.67), chronic corticosteroid use (OR 4.04, 1.40-11.60) and presentation with CIED-related infective endocarditis (CIED-IE), (OR 5.6, 2.25-13.92) were associated with increased odds of short-term mortality. Independent predictors of long-term mortality on multivariable model included patients' age (hazard ratio for 10-year increase 1.2, 95% CI 1.06-1.36), CHF (HR 2.01, 1.42-2.86), metastatic malignancy (HR 5.99, 1.67-21.53), corticosteroid use (HR 1.97, 1.22-3.18), renal failure (HR 1.94, 1.37-2.74) and CIED-IE (HR 1.68, 1.17-2.41). Our investigation provides some novel insights into predictors of short- and long-term mortality in CIED infection cases. While comorbid conditions and immunocompromised host status were primary determinants of both short- and long-term mortality, complicated device infection (CIED-IE) is the only predictor that presents an opportunity for intervention where mortality may be reduced by early diagnosis and expedited device removal.

Objectives: Clinicians need to identify which patients presenting with S. aureus bacteremia (SAB) have underlying cardiovascular implantable electronic device (CIED) infection and therefore need device extraction. The goal of this study was to identify clinical predictors of CIED infection in patients presenting with SAB. Methods: We retrospectively reviewed all cases of SAB in CIED recipients at Mayo Clinic from Jan 2001 to Dec 2011. CIED infection was defined using clinical, microbiologic and echocardiographic criteria. Patients who presented with clinical signs of CIED pocket infection were excluded. A multivariable model was developed to identify independent predictors of CIED infection. Model discrimination was summarized using the area under a receiver operating characteristics curve (AUC). Results: Among the 131 patients with SAB and CIED, 45 (34%) had underlying CIED infection. Permanent pacemaker (PPM) devices (OR 3.90, 95% CI 1.65-9.23, p=0.002), >1 device-related procedure (OR 3.30, 95% CI 1.23-8.86, p=0.018), and duration of SAB ≥4 days (OR 5.54, 95% CI 3.32-13.23, p <0.001) were independently associated with an increased risk of CIED infection. The AUC for this multivariable model was 0.79 indicating good discriminatory capacity to separate SAB patients with and without CIED infection. Various combinations of these three features and the corresponding predicted probabilities of CIED infection are summarized in Table. Conclusions: An individual patient’s risk of underlying CIED infection can be calculated based on the type of device, number of device-related procedures, and duration of SAB. Patients without any of these high-risk features have very low risk of underlying CIED infection and may be monitored closely without immediate device extraction.

Background: In 2007, the American Heart Association (AHA) infective endocarditis (IE) prevention guidelines recommended that antibiotic prophylaxis before invasive dental procedures for the “moderate risk” (MR) group, which represented the bulk of patients who were to receive prophylaxis before 2007, be eliminated. This decision was met with much concern among some healthcare providers and that concern persists today. We therefore evaluated dental office records in Olmsted County (OC), Minnesota to determine whether patients included in the MR group continue to receive antibiotic prophylaxis despite the 2007 AHA recommendations. Methods: Eligible patients include all adult (≥18 years) residents of OC, classified as having MR cardiac condition for IE (i.e. mitral valve prolapse [MVP], bicuspid aortic valve [BAV], hypertrophic obstructive cardiomyopathy [HOCM], acquired valvular dysfunction [AVD]), with at least one dental visit between January 1, 2005 and June 1, 2015. Eight dental offices located within OC were sampled to identify both dental procedures and whether antibiotic prophylaxis was administered according to AHA guidelines. Results: We identified 334 MR patients. Approximately 62% of MR patients received antibiotic prophylaxis prior to the change in AHA guidelines in 2007. There was a decrease to 7% post-2007 AHA guidelines (P<.001). The magnitude of decline was greater among visits for dental cleanings (from 63% to 6%), as compared to other invasive procedures (57% to 11%; P=0.003) (Figure 1). AVD was the most common cardiac condition (85%), followed by MVP (8%), and BAV (4%). Conclusion: Following publication of the 2007 AHA IE prevention guidelines, there was a rapid, 9-fold decrease in antibiotic prophylaxis in patients with MR cardiac conditions who underwent invasive dental procedures in OC. These data are also critical as we attempt to evaluate the impact, if any, of this practice on the incidence of IE due to viridans group streptococci.

AbstractBackgroundThe American Heart Association (AHA) guidelines for infective endocarditis (IE) management recommend end-of-therapy (EOT) echocardiography (ETE) to “establish a new baseline” and based on “expert opinion.”MethodsMedical records of IE patients treated between January 2005 and December 2011 were reviewed. Utilization of ETE and cumulative incidence of re-treatment with antimicrobials or cardiovascular surgery (re-Rx/CVS) within 1 year after EOT were evaluated.ResultsA total of 243 patients completed clinical follow-up at EOT and 170 at 1 year after EOT. One hundred seventy-seven of 243 (72.8%) underwent ETE, the majority (51.4%) transthoracic echocardiography. One hundred thirty-three of 177 (75.1%) were without new/worsened signs or symptoms (new/w-SSx). One hundred forty-one of 177 (79.7%) overall and 117/133 (87.9%) patients without new/w-SSx had no new ETE findings as compared with initial echocardiography. Among 36/177 (20.3%) with new ETE findings, 20/36 (55.6%) had new/w-SSx; ETE findings were more likely in patients with new/w-SSx (39.2% vs 8.3%; P &lt; 0.001) at EOT. Patients were at increased risk of re-Rx/CVS with either new ETE findings (hazard ratio [HR], 25.86; 95% confidence interval [CI], 7.64–87.56; P &lt; .001) or new/w-SSx (HR, 5.35; 95% CI, 2.87–9.95; P &lt; .001). The highest risk of re-Rx/CVS was in patients with both new/w-SSx and new ETE findings (HR, 45.94; 95% CI, 19.07–110.71). Conversely, only 7/187 (3.4%) patients without new/w-SSx who had an ETE required re-Rx/CVS.ConclusionsThe majority of patients without new/w-SSx at EOT will not have new ETE findings or need re-Rx/CVS within 1 year after EOT. EOT new/w-SSx is associated with new ETE findings and predicts the need for re-Rx/CVS. Further study is needed to determine whether patients without new/w-SSx need ETE.

ABSTRACT Eighty-nine staphylococcal isolates recovered from patients with bacterial endocarditis at the Mayo Clinic from 1980 to 1999 were studied to determine the prevalence of Staphylococcus lugdunensis among clinical isolates of staphylococci causing endocarditis. Four isolates, all from patients with native mitral valve endocarditis, were identified as S. lugdunensis .

ABSTRACT The 16S rRNA sequences of enterococcal species E. faecium , E. faecalis , E. gallinarum , E. casseliflavus/flavescens , E. dispar , E. pseudoavium , E. sulfureus , E. malodoratus , E. raffinosus , E. cecorum , E. hirae , E. saccharolyticus , E. seriolicida , E. mundtii , E. avium , E. durans , E. columbae , and E. solitarius are presented herein. These data were utilized to confirm the species identification of two nonmotile E. gallinarum isolates which had been previously phenotypically identified as E. faecium . The implications of this finding are discussed.

Diagnosis of persistent infection at the time of reimplantation for staged revision of infected arthroplasties is challenging. Implant sonication culture for the diagnosis of prosthetic joint infection (PJI) has improved sensitivity compared to standard periprosthetic tissue culture.

Abstract Background Nutritionally variant streptococci (NVS) are an infrequent cause of infective endocarditis (IE) and management recommendations are based on weak levels of evidence largely derived from case reports, small case series, and animal models of experimental endocarditis. Moreover, taxonomic changes have led to some confusion in designation of these organisms. Methods We retrospectively collected and analyzed data from 33 patients with NVS IE from 1970 to 2017. Only patients who met modified Duke Criteria for IE were included. Results Mean patient age was 55 years and 61% were males. The most common comorbidities included diabetes mellitus (12%), malignancy (3%), heart failure (16%), coronary artery disease (25%), and chronic liver disease (9%). Predisposing valve abnormalities included rheumatic heart disease (11%), bicuspid aortic valve (22%), transplant valvulopathy (3%), mitral valve prolapse (3%), and congenital heart disease (11%). Cultures were reported as NVS (70%), Granulicatella species (18%) and Abiotrophia species (12%). Echocardiogram findings included vegetations (67%), new regurgitation (55%), perivalvular abscess (3%), mitral valve prolapse (3%), and ruptured mitral valve chordae (3%). Both prosthetic (26%) and native valve IE (74%) was seen, and the valves involved were aortic (37%), mitral (50%) and both aortic and mitral (13%). Complications were seen in 27% of patients, including heart failure (17%), splenic infarct (11%), stroke (8%), mycotic aneurysm (3%), and glomerulonephritis (2%). In vitro susceptibility to penicillin, ceftriaxone, and vancomycin was 88%, 80%, and 100%, respectively. The majority (77%) of patients were treated with a combination of β-lactam and aminoglycoside. Median duration of treatment was 33 days. Surgery was performed in 50% of patients with no significant difference in survival between those who were treated with combined medical/surgical treatment and those treated with medical therapy alone. Overall survival at 1, 4, and 10 years was 93%, 83%, and 66%, respectively. Conclusion IE due to NVS is a rare entity and is associated with a high rate of serious complications and may involve multiple valves. Long-term, two-thirds of the patients survived more than 10 years. Disclosures All authors: No reported disclosures.

ABSTRACT The MICs of HMR 3004 and HMR 3647 at which 90% of beta-lactamase-producing Haemophilus influenzae isolates were inhibited were 4 and 2 μg/ml, respectively. Both HMR 3004 and HMR 3647 were active against beta-lactamase-producing H. influenzae in a murine model of experimental pneumonia. As assessed by pulmonary clearance of H. influenzae , HMR 3004 was more effective ( P < 0.05) than was azithromycin, ciprofloxacin, clarithromycin, erythromycin A, pristinamycin, or HMR 3647 in this model.