Baddour, Larry M.

Abstract Background Cardiac valve tissue obtained during the surgical management of infective endocarditis (IE) and sent for culture may influence postoperative antibiotic therapy. We sought to identify clinical and microbiologic risk factors associated with positive valve cultures (PVC) and IE relapses in a cohort of patients undergoing surgical management. Methods This is a retrospective, multi-center study of patients with surgical management during the acute (<42 days) course of IE-directed antibiotic therapy. The rate of PVC, IE relapse, and mortality were collected. Univariate and multivariable logistic regressions were performed to identify risk factors associated with PVC. Results Of 113 patients included, 36 (31.9%) had PVC. Univariate and multivariable analyses showed preoperative antibiotic duration and pathogens were associated with PVC. Median (IQR) days of preoperative antibiotics were 6.5 (4.0-11.0) for patients with PVC compared to 13.0 (8.0-21.0) for those with negative valve cultures (NVC). In a multivariable model, preoperative antibiotic administration decreased the risk of PVC (OR 0.85 per day, CI 0.77-0.91). Enterococcal IE increased the risk of PVC compared to streptococcal IE (OR 4.16, CI 1.07-17.48). Of note, 33 (63.2%) patients with NVC received a median (IQR) of 8 (5, 18.5) days of intravenous antibiotics per patient. Only one IE relapse was identified and occurred in a patient with NVC. Conclusions Both preoperative antibiotic duration and causative pathogen were associated with PVC. IE relapses were rare and unrelated to PVC. There may be an opportunity to shorten postoperative antibiotic durations following surgical management in patients with IE.

Background: Aortic endograft infection (AEGI) is a rare complication of abdominal endovascular aortic repair (EVAR) and thoracic endovascular aortic repair (TEVAR). Surgical explantation with reconstruction is recommended, but data on medical management remain limited. We present our institutional experience with AEGI. Objective: To describe the clinical presentation, microbiology, management strategies, and outcomes of patients with AEGI, with the aim of addressing current gaps in the literature and informing future research to improve patient outcomes. Design: Retrospective descriptive study. Methods: Adult patients admitted with AEGI at our institution between January 2017 and August 2024 were identified using ICD-10 codes and confirmed using the Management of Aortic Graft Infection Collaboration (MAGIC) diagnostic criteria. Clinical, microbiological, radiographic, treatment, and outcome data were collected and analyzed. Results: We screened 517 patients, and 46 met AEGI criteria (EVAR 54%, TEVAR 46%). Most (63%) presented with late-onset infections (⩾3 months). Fever (54%) and sepsis (48%) were common presenting symptoms. Computed tomography (CT) (85%) was the primary imaging modality. Blood cultures were positive in 54% of the cases, with Staphylococcus aureus being the most common monomicrobial pathogen (24%), and 24% of cases were polymicrobial. The majority (67%) received combined medical and surgical therapy. Chronic antibiotic suppressive therapy was used in 34 (74%), most often tetracyclines (33%). Overall, treatment success rates were similar between surgical and medical groups (58% vs 60%, p = 0.250) with comparable mortality. However, relapses were more frequent in the medical-only group (33% vs 16%, p = 0.185). Conclusion: Most patients presented with late-onset AEGI. Fever was absent in nearly half of cases, and blood cultures were positive in only 54%. Overall, surgical and medical therapy had similar success, though relapses were more frequent in those treated medically alone.

Isolated pulmonary valve endocarditis (PV-IE) is a rare condition. Its epidemiology, clinical profile, and management remain poorly characterized. A systematic review was conducted to provide a contemporary characterization (2020–2025) of adult cases with isolated PV-IE. Individuals with previous cardiac surgeries, cardiac implantable electronic devices (CIEDs), or long-term venous catheters were excluded. Of 1902 citations identified, 72 studies were selected with 79 eligible cases, mostly case reports. Patients were predominantly male (78.5%) with a median age of 43 years. Congenital heart disease (CHD) and injection drug use (IDU) were risk factors in 30.4% and 27.8% of cases, respectively, while 41.8% had neither (No-CHD/IDU group). Staphylococcus aureus was the leading pathogen (39%), followed by streptococci (16.5%) and Enterococcus faecalis (8.9%). Vegetations were large (median, 19.5 mm), and pulmonary septic emboli highly prevalent (~93% of cases). More than half (54.4%) of patients underwent surgery. Hospital mortality was low (7.6%). Differences across risk factor subgroups were observed, with higher median age in No-CHD/IDU patients and more staphylococcal etiology in patients with IDU, although treatment approaches and mortality did not differ. This review highlights distinct characteristics and the overall favorable short-term prognosis of isolated PV-IE, underscoring the need for larger, systematically collected datasets.

Abstract Background Knowing the prevalence of patent foramen ovale (PFO) and the increasing number of people who inject drugs (PWID) with right-sided infective endocarditis (RSIE), we aimed to better characterize the syndrome of injection drug use, RSIE, and PFO with systemic embolic events. Method A systematic search across multiple databases was independently screened using predefined criteria (from inception until September 2025). Published cases of adult PWID diagnosed with RSIE and ischemic stroke or other systemic embolic event were included, provided they had PFO assessment. Individuals were excluded if they had cardiac implantable electronic device (CIED) infections or any other conditions associated with systemic or paradoxical embolism. Results The review identified 13 studies with 14 young patients, mostly without comorbidities, predominantly infected with Staphylococcus aureus. In most cases, echocardiography revealed large tricuspid valve vegetations. Neuroimaging confirmed multiple ischemic infarcts, while 5 patients showed emboli outside the central nervous system (4 of them as the only systemic embolism). At least 11 (79%) patients had echocardiographic evidence of right-to-left shunting. Management included cardiac surgery in 6 cases that involved valve replacement or repair, percutaneous PFO closure in 2 cases, and percutaneous mechanical aspiration in 1 case. Three patients (21%) died during hospitalization, and only 27.3% patients had outpatient follow-up. Conclusions RSIE with systemic embolism in PWID with PFO has rarely been reported, affects younger patients without sex predominance, and was usually due to S. aureus with large tricuspid vegetations. Right-to-left shunting was characteristic, and outcomes were poor despite combined medical, surgical, and interventional therapies.

Abstract The practice patterns of fluorine 18–labeled fluorodeoxyglucose positron emission tomography/computed tomography ([18F] FDG PET/CT) use in cardiac implantable electronic device infection remain undefined. Among 258 Emerging Infections Network respondents, 69% reported never or rarely using [18F] FDG PET/CT. Limited access and insurance barriers were the most common obstacles.

Abstract Introduction Endogenous endophthalmitis (EE) is a rarely reported complication of infective endocarditis (IE). In an international series, we sought to determine the clinical and microbiological profile, treatment and outcome of patients presenting with IE-related EE. Methods Cases of EE recorded from 2014 to 2023 in 9 centers in Europe and the United States were collected. Results were compared to a matched control group. Results Sixty-six patients with EE were reported, mean age 65.2± 14.9 years, 71% (n=47) male. Blood cultures were positive in 90% (60 cases) of patients, with a predominance of streptococci (46%, n=30). As compared with the control group (n=264), the EE group presented with more frequent diabetes (34vs 20%, p=0.02), history of cirrhosis (9 vs 3%, p=0.04), glomerulonephritis (15 vs 0.3%, p<0.001), embolism before admission (92 vs 55%, p<0.001), and Janeway lesions (9 vs 1%, p=0.002). Streptococcal infection (46 vs 26%, p= 0.003) was more frequent and enterococcal infection (0 vs 18%, p< 0.001) less frequent in the EE group. The main ocular symptoms were a decrease in visual acuity (96%), red eye (55%) and ocular pain (55%). Treatment of EE consisted of intravitreal antibiotic injection in 55 (83%) patients and vitrectomy in 17 (26%). Improvement of visual acuity was observed in 36 (55%) patients but 43 (65%) still experienced severe impairment at one-year with 20 (30%) patients classified as legally blind. Conclusion EE is a serious complication of IE with severe residual vision impairment. Patients with IE should be evaluated for ocular complications, since early detection of EE is crucial to prevent delays in management and to preserve visual function.Severe endogenous endophthalmitis Endophthalmitis versus control group

Abstract Aims Endogenous endophthalmitis (EE) is a rarely reported complication of infective endocarditis (IE). In an international series, we sought to determine the clinical and microbiological profile, treatment, and outcome of patients presenting with IE-related EE. Methods and results Cases recorded from 2014 to 2023 in nine centres in Europe and the United States were collected. Results were compared to a matched control group. Conclusion Sixty-six patients with EE were reported, mean age of 65.2 ± 14.9 years, 71% (n = 47) male. Blood cultures were positive in 97% (64 cases) of patients, with a predominance of streptococci (46%, n = 30). As compared with the control group (n = 264), the EE group presented with more frequent diabetes (35% vs. 21%, P = 0.02), history of cirrhosis (9% vs. 3%, P = 0.04), glomerulonephritis (15% vs. 0.4%, P < 0.001), embolism before admission (92% vs. 55%, P < 0.001), and Janeway lesions (9% vs. 1%, P = 0.002). Streptococcal infection (46% vs. 26%, P = 0.001) was more frequent and Enterococcal infection (0% vs. 18%, P < 0.001) less frequent in the EE group. The main ocular symptoms were a decrease in visual acuity (96%), red eye (55%), and ocular pain (55%). Treatment of EE consisted of intravitreal antibiotic injection in 55 (83%) patients and vitrectomy in 17 (26%). Improvement of visual acuity was observed in 36 (55%) patients. Conclusion EE is a serious complication of IE with severe residual vision impairment. Patients with IE should be evaluated for ocular complications, since early detection of EE is crucial to prevent delays in management and to preserve visual function.

Abstract Background Recent clinical trial evidence supports broader use of partial oral therapy (POT) for infective endocarditis (IE), yet real-world uptake in the U.S. has not been investigated. Methods Adult infectious diseases (ID) physician members of the Infectious Diseases Society of America Emerging Infections Network were surveyed in April–May 2025. A 10-item instrument captured frequency of POT, organism-specific influence, decision factors, barriers, and facilitators. Results Among 1531 members, 516 (34%) responded; 452 (88%) of them managed IE. POT was uncommon: 16% never used, 53% used in ≤10% of cases, and only 10% used in >25% of patients. Frequent POT rose with caseload (23% in physicians treating >50 IE cases year vs ≤9% in lower-volume groups, P < .001) and with fewer years in clinical practice (13% in <5 yrs vs 5% in ≥25 yrs, P = .013). Comfort with POT depended on the pathogen: 66% were comfortable switching for Streptococcus spp., 52% for Gram-negative bacilli, 19% for methicillin-resistant Staphylococcus aureus. Three quarters of those who used POT finished with a single agent. In people who inject drugs, 34% of physicians often or always considered an oral regimen. Availability of an active oral agent (75%) and the pathogen involved (69%) were the leading decision drivers; principal barriers were fear of relapse (72%), adherence concerns (53%), and insufficient evidence (48%). Respondents most desired clearer guidelines (75%) and additional data (71%). Conclusions U.S. adult ID physicians adopt POT for IE sparingly. Updated IE treatment guidelines, additional clinical trial data, and broader access to complex outpatient antimicrobial therapy services may facilitate wider adoption.