DeSimone, Daniel C.

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.

Abstract Background Despite safety communications from the Food and Drug Administration (FDA) regarding the outbreak of Mycobacterium chimaera infections (MCIs) from contaminated heater-cooler devices, new cases continue to be identified. Methods We retrospectively reviewed confirmed cases of MCI that were managed at Mayo Clinic sites (Arizona, Florida, and Minnesota) from 09/2015 to 01/2021. Clinical histories including prior cardiovascular surgery were recorded. Diagnostic workup including ophthalmologic examination, imaging, and laboratory testing was reviewed. Treatment and survival outcomes on follow-up were obtained. Results Twelve patients with MCI were included. All patients had aortic valve or graft replacement. Five patients had their surgical procedures following the 10/15/2015 FDA safety communication. The mean time from surgery to symptom onset (range) was 32 (13–73) months. Ten of 11 patients who underwent ophthalmologic examination had chorioretinal abnormalities. Three patients who underwent microbial cell-free deoxyribonucleic acid sequencing tested positive for M. chimaera, which was subsequently confirmed with blood culture growth. Echocardiography and positron emission tomography/computed tomography (PET/CT) revealed evidence of prosthetic valve/graft infection in 7/12 (58.3%) and 6/10 (60.0%) of cases, respectively. Seven patients (58.3%) underwent redo cardiovascular surgery. Of these, 1 patient died 2 days postdischarge, 1 experienced spinal osteomyelitis relapse, and another had interval prosthetic valve fluorodeoxyglucose (FDG) uptake on PET/CT suspicious for recurrent infection. Among 4 patients on medical therapy only, 3 expired or transitioned to hospice during follow-up. Conclusions MCI continues to occur despite the FDA communications. Incorporation of ophthalmologic examination and use of advanced tools may improve MCI diagnosis. The mortality in these patients is high even with aggressive surgical/medical management.

AbstractBackgroundOptimal timing of cardiovascular implantable electronic device (CIED) re‐implantation following device removal due to infection is undefined. Multinational guidelines reflect this and include no specific recommendation for this timing, while others have recommended waiting at least 14 days in cases of CIED related infective endocarditis (CIED‐IE). The current work seeks to clarify this issue.MethodsWe retrospectively reviewed institutional data at Mayo Clinic, Minnesota of patients aged ≥ 18 years who developed CIED‐IE from January 1, 1991 to February 1, 2016. CIED‐IE was defined as echocardiogram reported device lead or valvular vegetation. Regression analyses were used to relate the risk of clinical outcomes to the interval between CIED removal and re‐implantation and the location of vegetations.ResultsA total of 109 patients met study inclusion criteria. A majority (68.8%) of patients were men and the median age was 68.0 years. Transoesophageal echocardiogram (TEE) was performed in 95.4% of patients, with valve vegetations detected in 33.9% (n = 37). Survival analysis comparing patients in whom device re‐implantation was < 14 days vs. ≥14 days, and further categorized by those with and without valve vegetation, showed a significant difference (P = 0.028); patients with valve vegetation and reimplantation interval < 14 days had the lowest (58.7%) 12‐month survival. When adjusted for valve vegetation, longer time interval for reimplantation trended toward increased hospital length of stay (P = 0.079).ConclusionOur findings suggest that the recommended 14‐day delay between CIED extraction and re‐implantation in CIED‐IE patients is associated with a survival benefit, but longer length of hospital stay following re‐implantation.

A 78-year-old man with an implantable cardioverter-defibrillator (ICD) presented with chills and malaise. His history was significant for heart failure with reduced ejection fraction and complete heart block. He had undergone permanent pacemaker placement that was later upgraded to an ICD 5 years before his presentation. Physical examination revealed an open wound with surrounding erythema overlying the device site. Blood cultures obtained on admission were negative. Transesophageal echocardiogram did not show valve or lead vegetations. He underwent a prolonged extraction procedure. Postoperatively, he developed septic shock and cultures from the device, and repeat peripheral blood cultures grew Staphylococcus simulans and Staphylococcus epidermidis. He was treated with intravenous vancomycin but had refractory hypotension, leading to multiorgan failure. He later expired after being transitioned to comfort care. The patient may have acquired S. simulans by feeding cows on a nearby farm, and the prolonged extraction procedure may have precipitated the bacteraemia.

Introduction: Cardiovascular implantable electronic devices (CIED) infections are frequently complicated with bloodstream infection (BSI). Complete device removal and prolonged antimicrobial therapy is essential for cure. The frequency of persistent BSI after source control (device extraction) is not well described. This study aims to assess the utility of repeat blood cultures (BC) after device extraction as recommended by the American Heart Association (AHA) guidelines. Methods: We selected patients who presented with BSI in the setting of CIED infection and underwent device removal at Mayo Clinic Rochester between 2012 and 2017. Cases where BC were not drawn prior to extraction, or repeated within 72 hours of device extraction, or met criteria for contamination were excluded. Results: Of 656 patients who underwent CIED extraction for device infection, 190 with post-extraction BC met study criteria. Among the final study cohort (Table 1), 159 patients had negative BC, while 31 had positive BC following CIED extraction. Pre-extraction, the most common causative organism was Staphylococcus aureus (91/190, 48%) (Figure 1a). Post-extraction, 22 of the 31 (71%) cases of persistent BSI were due to S. aureus (Fig 1b). The median duration of BSI was not significantly different between negative and positive BC groups (3 versus 4 days, p=0.92). Conclusions: Majority of patients had resolution of BSI after CIED extraction. S. aureus was the most common cause of persistent BSI post-extraction. Our findings support the AHA guidelines of repeating BC after device extraction, especially for S aureus .

Abstract Background Nocardial brain abscesses are rare, and published literature describing brain abscesses due to Nocardia species is limited to individual case reports or small series. We report one of the largest contemporary retrospective studies describing risk factors, diagnostic evaluation, management, and outcomes of nocardial brain abscess. Methods Retrospective review of all adults with brain abscess due to culture-confirmed Nocardia species at our institution between January 1, 2009, and June 30, 2020. Results Overall, 24 patients had nocardial brain abscesses during the study period. The median age at presentation was 64 years, and 62.5% were immunocompromised. Pulmonary and cutaneous infections were the most common primary sites of nocardial infection. All 24 patients had magnetic resonance imaging performed, and the frontal lobe was the most commonly involved. The most common organism isolated was Nocardia farcinica, followed by Nocardia wallacei and Nocardia cyriacigeorgica. Thirteen patients were managed with antimicrobial therapy alone, while 11 had both medical and surgical management. In all patients, dual therapy was recommended for the initial 6 weeks of treatment, and 22 patients received at least 1 oral agent as part of their final antibiotic regimen, predominantly trimethoprim-sulfamethoxazole and linezolid. Fourteen patients achieved complete clinical and radiographic resolution of infection. Conclusions Nocardia is an important cause of brain abscess in the immunocompromised host. Early diagnostic and therapeutic aspiration may help health care providers confirm the diagnosis, choose an appropriate antimicrobial regimen, and achieve source control.

Abstract Background A population-based study of infective endocarditis (IE) in Olmsted County, Minnesota, provides a unique opportunity to define temporal and seasonal variations in IE incidence over an extended time period. Methods This was a population-based review of all adults (≥18 years) residing in Olmsted County, Minnesota, with definite or possible IE using the Rochester Epidemiology Project from January 1, 1970, through December 31, 2018. Poisson regression was used to characterize the trends in IE incidence; models were fitted with age, sex, calendar time, and season, allowing for nonlinearity and nonadditivity of their effects. Results Overall, 269 cases of IE were identified over a 49-year study period. The median age of IE cases was 67.2 years, and 33.8% were female. The overall age- and sex-adjusted incidence of IE was 7.9 cases per 100 000 person-years (95% CI, 7.0–8.9), with corresponding rates of 2.4, 2.4, 0.9, and 0.7 per 100 000 person-years for Staphylococcus aureus, viridans group streptococci (VGS), Enterococcus species, and coagulase-negative staphylococci IE, respectively. Temporal trends varied by age, sex, and season, but on average IE incidence increased over time (P = .021). Enterococcal IE increased the most (P = .018), while S. aureus IE appeared to increase but mostly in the winter months (P = .018). Between 1996 and 2018, the incidence of VGS IE was relatively stable, with no statistically significant difference in the trends before and after the 2007 AHA IE prevention guidelines. Conclusions Overall, IE incidence, and specifically enterococcal IE, increased over time, while S. aureus IE was seasonally dependent. There was no statistically significant difference in VGS IE incidence in the periods before and after publication of the 2007 AHA IE prevention guidelines.

Abstract Background Bloodstream infections (BSIs) confer an increased risk of infective endocarditis (IE) in patients with a prosthetic cardiac valve. This relationship is less well established in patients undergoing valve repair. We conducted a retrospective population-based study to determine the incidence of BSIs following valve repair and identify risk factors associated with the development of IE. Methods The Rochester Epidemiology Project (REP) data linkage system was used to identify all persons who underwent valve repair in a 7-county region in Southeastern Minnesota between January 1, 2010 and December 31, 2018. Medical records were screened for the development of a BSI from time of procedure until May 15, 2020. Patients were classified as having BSI only, BSI with IE at outset, or BSI with subsequent development of new IE. IE at outset was defined as cases where IE was diagnosed at the time of initial positive blood culture. Results A total of 387 patients underwent valve repair surgery. A total of 31 (8%) patients subsequently developed a BSI, 4% within one year of surgery. Seventeen patients underwent mitral repair with annuloplasty, 9 underwent tricuspid annuloplasty, and 5 had concurrent repairs. Median time to the development of BSI was 338 days. Of the 31 patients with BSI, 4 (13%) had BSI with IE at outset. No patients developed IE subsequent to BSI, Enterococcus spp. was responsible for 3 cases of IE, and MSSA for 1. All cases occurred within one year of surgery. Given the low incidence, statistical analysis of associated risk factors for IE was not feasible. All patients with BSI and IE at outset, however, died by the end of the study period, versus 11/27 in the BSI only group. Conclusion Incidence of BSIs was higher in patients undergoing cardiac valve repair than in the general population. The incidence of IE with a BSI was 13%, which is lower than what has been previously published. It is notable that all cases of IE occurred within one year of surgery. Recognizing that endothelialization of device surfaces occurs, it is tempting to speculate that the risk of IE may be time dependent and may decline over time. Subsequent investigation of this theory is underway. Disclosures Larry M. Baddour, MD, Boston Scientific (Consultant)

Abstract Background Transcatheter aortic valve replacement (TAVR) was initially approved as an alternative to surgery for patients at high surgical risk. However, it is now being considered for patients with intermediate and low surgical risk. This will result in the expansion of patient pool for TAVR; hence it is of interest to ascertain risk of blood stream infection (BSI) and infective endocarditis (IE) following TAVR. We aim to study the incidence, epidemiology and risk factors associated with IE in patients who underwent TAVR and subsequently developed a BSI. Methods A population-based study was conducted in 7 counties in southeastern Minnesota using the expanded Rochester Epidemiology Project (E-REP) for all adult (≥18 years) patients who underwent TAVR from January 1st, 2010 to December 31st, 2018. Transcatheter procedures that included replacement of either the aortic or mitral valve were included. Medical records were screened for development of BSI from time of TAVR until May 15th, 2020. Patients were classified as having BSI only, BSI with IE at outset, or BSI with subsequent development of new IE. ‘Early’ IE was defined as that occurring &lt; 12 months following TAVR, with subsequent cases defined as ‘late’ IE. Results A total of 247 patients underwent TAVR during the study period. There were 24 patients with of BSI and 10 (42%) developed IE with an annual incidence of 5 per 1000 persons-years. Median age for patients who developed IE was 85.4 years. Male gender was affected predominantly (70%). Six developed IE at outset of BSI, while four developed IE subsequent to IE. The median time to development of IE was 791 days following TAVR. There was an equal number of early and late IE cases (n=5). The most common pathogen causing IE was viridians group streptococci (n=4) followed by enterococci and coagulase-negative staphylococci with 2 patients each. Mean Charlson comorbidity index was 6.6. Two patients with IE died before resolution of infection (20%). Conclusion The incidence of BSI and subsequent IE in patients with TAVR was low in our population. Due to the small number of BSI and IE cases, statistical analysis was not feasible. An analysis of all cases seen at Mayo Clinic is planned since the number of cases would be much higher to investigate potential risk factors associated with BSI and IE. Disclosures Larry M. Baddour, MD, Boston Scientific (Consultant) M. Rizwan Sohail, MD, Aziyo Biologics (Consultant)Medtronic Inc (Consultant, Research Grant or Support)

AbstractBackgroundThe improved life expectancy observed in patients living with human immunodeficiency virus (HIV) infection has made age‐related cardiovascular complications, including arrhythmias, a growing health concern.HypothesisWe describe the temporal trends in frequency of various arrhythmias and assess impact of arrhythmias on hospitalized HIV patients using the Nationwide Inpatient Sample (NIS).MethodsData on HIV‐related hospitalizations from 2005 to 2014 were obtained from the NIS database using International Classification of Diseases, 9th Revision (ICD‐9) codes. Data was further subclassified into hospitalizations with associated arrhythmias and those without. Baseline demographics and comorbidities were determined. Outcomes including in‐hospital mortality, cost of care, and length of stay were extracted. SAS 9.4 (SAS Institute Inc., Cary, NC) was utilized for analysis. A multivariable analysis was performed to identify predictors of arrhythmias among hospitalized HIV patients.ResultsAmong 2 370 751 HIV‐related hospitalizations identified, the overall frequency of any arrhythmia was 3.01%. Atrial fibrillation (AF) was the most frequent arrhythmia (2110 per 100 000). The overall frequency of arrhythmias increased over time by 108%, primarily due to a 132% increase in AF. Arrhythmias are more frequent among older males, lowest income quartile, and nonelective admissions. Patients with arrhythmias had a higher in‐hospital mortality rate (9.6%). In‐hospital mortality among patients with arrhythmias decreased over time by 43.8%. The cost of care and length of stay associated with arrhythmia‐related hospitalizations were mostly unchanged.ConclusionsArrhythmias are associated with significant morbidity and mortality in hospitalized HIV patients. AF is the most frequent arrhythmia in hospitalized HIV patients.