Explore the vast range of titles available.

Background Guidelines suggest treating fully penicillin-susceptible Enterococcus faecalis strains causing infective endocarditis with amoxicillin combined with gentamicin or ceftriaxone, but clinical evidence to support this practice is limited and monotherapy cohorts were excluded from studies. We describe antibiotic treatment, complications, and outcomes in patients with Enterococcus faecalis infective endocarditis, specifically comparing monotherapy versus combination therapy. Methods Retrospective analysis of prospectively collected cohort of patients with definite or possible infective endocarditis from 2 English centres between 2006 and 2021. The primary outcome was 30-day mortality. Secondary outcomes included acute kidney injury, relapse, and clinical cure. Results 178 individuals were included: median age was 72 years (interquartile range 60–79), male sex majority (138, 78%) and mostly native valve endocarditis (108, 61%). Thirty-nine patients (22%) received monotherapy (penicillin/glycopeptide/linezolid/daptomycin), 128 (72%) combination with gentamicin, 11 (6%) combination with ceftriaxone. Patients on combination therapy with gentamicin had a statistically significant lower 30-day mortality than those treated with monotherapy (21 (16.4%) versus 15 (38.5%) p  = 0.035) and higher rates of clinical cure (101 (78.9%) versus 23 (59.0%) p  = 0.018). Patient receiving gentamicin were more likely to experience acute kidney injury (64 (50%) versus 11 (28.2%) p  = 0.057). Ceftriaxone combination was associated with poor outcomes, but the sample size was small. Conclusion Patients treated with combination gentamicin therapy had better clinical outcomes than patients treated with monotherapy. Low-dose gentamicin regimens were associated with acute kidney injury. Patients treated with combinations were different to those treated with monotherapy and confounding remains a concern with observational analyses. An adequately powered clinical trial is needed to determine optimal treatment of enterococcal endocarditis. Clinical trial number Not applicable.

[...]multiple contributory factors are likely, including (A) an ageing population, (B) increased use of both intra-cardiac (including permanent pacemakers, implantable cardioverter-defibrillators, surgical and transcatheter heart valves) and vascular devices (including those used for chronic haemodialysis), (C) epidemic levels of opioid addiction and associated injection drug use, (D) emergence of staphylococci and enterococci (neither of which are targeted by current antibiotic prophylaxis strategies) as more common causative organisms, and (E) greater clinical awareness of IE. [...]these findings are disturbing and contrast with reports of falling incidence in the USA4 and falling or more modest increases in Europe.5 European guidelines still provide a Class IIA recommendation for the use of antibiotic prophylaxis in patients at highest risk of IE undergoing specific dental procedures,6 which is similar to the American Heart Association guidelines from 2007 (although there is little reference to this controversial topic in their most recent scientific statement).7 Figure 1. While staphylococcal, streptococcal and enterococcal species are responsible for 80%–90% of cases,1 9 Staphylococcus aureus is the most common causative organism in developed countries (accounting for 30%–35% of caseload).9 Indeed, healthcare-acquired IE now accounts for around 25% of cases as a consequence of increased use of indwelling lines and invasive procedures.9 Despite improvements in diagnosis and management, outcomes remain poor with in-hospital and 6-month mortality of 18% and 30%, respectively,1 9 S. aureus infection is one of the principal determinants of outcome, alongside advancing age, persistently positive blood cultures (despite appropriate antibiotic therapy) and the presence of significant comorbidities.1 6 9 Preventative measures beyond antibiotic prophylaxis remain essential, including meticulous attention to dental and cutaneous hygiene, maintained focus on the reduction of hospital acquired IE (particularly staphylococcal and enterococcal infection) and innovative measures to reduce biofilm formation. Relapse and recurrence are not infrequent and deferred surgery is often required for residual valve lesions—the Endocarditis Team should therefore also oversee follow-up at 1, 3, 6 and 12 months after admission in a specialised Endocarditis or Heart Valve clinic with ready access to imaging, microbiological and surgical expertise.6 This approach, which is strongly supported by international guidelines,6 7 has been shown to reduce 1-year mortality by more than 50% in one study (18.5% to 8.2%)12 and is arguably the single most important step forward in the management of IE in the past 20 years.

BackgroundThe first wave of the COVID-19 pandemic required rapid reconfiguration and reallocation of resources. We triaged all cardiac imaging requests from our referral network serving 2.5 million people, to our tertiary centre, performing only clinically urgent studies and cancelling non-urgent studies. Requesters received notification of cancellation in the same format as test reports and were encouraged to repeat their request when pandemic conditions had improved. The impact of this cancellation on patient outcomes is assessed.MethodsRetrospective analysis of routinely collected clinical and administrative data from the institutional data warehouse determined patient outcomes for those with cancelled and performed stress echocardiography, nuclear stress perfusion studies, cardiac CT angiography and cardiac MRI. Mortality data was drawn from the NHS spine. Data analysis was performed using R.Results1600 cardiac studies for 1592 patients were cancelled in April 2020, and 2234 cardiac studies were performed for 2184 patients between April and July 2020, representing high-risk outpatient requests. 41 patients who had cancelled scans died, and 105 patients with performed scans died (table 1). Of cancelled scans, 787 patients had a subsequent scan in some modality, of which 701 were the same modality as the original test. 761 patients had no repeat outpatient testing until October 2021. Mortality was higher in patients for whom scans were performed (log-rank p = 0.03, figure 1A). Non-elective admissions were higher in patients who had scans performed (4% in cancelled vs. 8% performed after 574 days of follow-up, log-rank p <0.001 figure 1B). Over the course of the pandemic, our wait-times for cardiac testing did not exceed the national standard of 16 weeks.Limitations: Data was not collected prospectively, due to the level of emergency; cancellation data may not be complete. All cause mortality under pandemic conditions cannot be extrapolated to non-pandemic situations.Abstract 160 Table 1Demographic and outcome data for patients with cancelled or completed cardiac scans during the first wave of the COVID-19 pandemicAbstract 160 Figure 1All cause mortality in patients with cancelled or completed outpatients cardiac tests from the time of the first round of cancellations (18/04/2020) at the beginning of the COVID-19 pandemic. Clinically urgent scans, as triaged by expert clinicians, were completed, and others cancelled. Mortality was greater for those with completed scans detected over a mean follow-up of 581 days. (B) Acute admissions to emergency, cardiac or cardiothoracic services in patients with cancelled or completed cardiac tests after cancellations of low-risk patients. In keeping with triage, patients with completed scans had worse outcomes. Patients with low-risk clinical features had a reassuring rate of admissionConclusionOur approach to diagnostic testing in cardiology during the first wave of the COVID-19 pandemic accurately identified and tested high-risk patients without causing harm to those at lower risk, demonstrated by higher admission rates in patients in whom tests were performed, and the absence of an adverse impact on mortality. 49% of patients underwent subsequent cardiac testing after a cancelled test. We maintained low waiting times throughout the pandemic.Conflict of InterestNone

Infective endocarditis (IE) is associated with high mortality and morbidity. The aim of this study was to investigate the impact of timing of echocardiography on IE complications. We studied 151 consecutive patients with definite IE. Valve destruction was defined as ≥1 of severe regurgitation, cardiac abscess, or fistula. A definitive echocardiogram was the first echocardiogram (transthoracic (TTE) or Transesophageal (TEE)) which identified pathology consistent with IE and further echocardiography was not required for the diagnosis. TTE and TEE were performed within 4 days of admission in 62% and 15% patients respectively. Definitive echocardiography was achieved with TTE in 60% patients and required additional TEE in 40% patients. Significantly more in-patient embolic events occurred when definitive echocardiography was performed late (≥4 days) compared with early (<4 days) (40% vs 14%, p = 0.043). A significantly greater proportion of patients who underwent late definitive echocardiography (≥4 days) required valve surgery (73% vs 56%, p = 0.04). Time to definitive echocardiography (odds ratio [OR] 1.015, p = 0.011), male gender (OR 1.254, p = 0.005) and age (OR 0.992, p = 0.002) were predictors of severe valve destruction. Late definitive echocardiography (OR 1.166, p=0.035) was a predictor of in-patient embolism. In conclusion, time to definitive echocardiography is an important predictor of valve destruction, embolic events, and subsequent valve surgery. Pathways to reduce delays to echocardiography are required in patients with suspected IE.

BackgroundHeart failure affects almost one million people in the UK with survival rates comparable to or worse than many cancers. Recent publications of the NICOR National Heart Failure Audit have focused attention on the need for improvement. This challenge is particularly acute in busy district general hospitals in London such as Whipps Cross University Hospital.ObjectiveWe aimed to investigate if the implementation of a simple one-page user friendly Whipps Cross Heart Failure Improvement Proforma- the ‘WHIP form’ in all medical wards could help improve the management of patients admitted with heart failure against standard quality measures.MethodsThe ‘WHIP form’ was introduced and implemented in all medical wards supported with a one-day educational seminar and a new dedicated heart failure email service.ResultsBetween June to September 2015, 106 patients with a primary admission diagnosis of heart failure were enrolled and managed using the ‘WHIP form’. Inpatient mortality remained stable at 11.3% with an average hospital stay of 13.5 days. The 30-day readmission rate halved from 14% to 7%. Patients with documented left ventricular systolic dysfunction on Echocardiogram had significant improvements in the prescription of prognostic medication on discharge: ACEi/ARBs prescription increased from 78% from 88% [10% improvement]. B-Blockers prescription increased from 68% to 95% [27% improvement].ConclusionThe initiation of an “easy to use” one page heart failure management proforma led to a dramatic reduction in 30-day readmission rates and significant increase in the prescription of prognostically important ACE inhibitors and B-blockers. If the reductions in 30-day readmissions are sustained, we estimate that our cost neutral intervention could translate to yearly savings of nearly £80K for Whipps Cross University Hospital alone.

IntroductionDiagnosing infective endocarditis (IE) is challenging. The modified Duke’s criteria have shortcomings. European Society of Cardiology guidance (2015) suggests a potential role of18F-Fluorodeoxyglucose positron emission tomography (PET), based on class C evidence. There is a lack of data for native valve IE (NVE).MethodsDual centre retrospective study of all patients with suspected IE, from 01/2010. Patients were classified as confirmed/probable/rejected IE pre- and post-PET, with incremental benefit assessed versus actual diagnosis. This was defined by surgical specimen or Endocarditis Team (MDT) consensus at least three months following index admission.ResultsPET was undertaken in 71 patients from 2010 to date; 59 since the inception of the MDT in October 2015 (male=50; mean age 60.6 y (range 19–89)). At discharge, 27/39 (69%) had confirmed NVE and 21/32 (66%) confirmed prosthetic IE (PVE). 30/71 (42%) patients required surgical intervention with concomitant device extraction in 7. Whilst Staphylococcus was isolated in 30/71 (42%) patients, 22/71 (31%) were peripheral blood culture-negative. PET sensitivity, specificity, positive and negative predictive values were 72%, 100%, 67% and 100% respectively in NVE, and 84%, 54%, 70% and 73% in PVE. PET highlighted 12/71 (16.9%) patients as having an alternative non-cardiac source of infection. Receiver Operating Characteristic (ROC) curves showed incremental benefit of PET over Duke’s criteria alone (AUC 0.875 vs 0.750, p=0.003) in NVE, though no difference in PVE (AUC 0.682 vs 0.613, p=0.649) compared to discharge diagnosis.ConclusionPET has incremental value above modified Duke’s criteria in diagnosing IE, especially in NVE. PET has reduced specificity in PVE, likely related to post-surgical uptake.

Background Infective endocarditis (IE) is a known but uncommon cause of cardioembolic stroke and there are rare but recognized cases of IE without an inflammatory response. Cutibacterium acnes is an increasingly recognized source of invasive infections, including IE, but diagnosis is challenging due to its low virulence and fastidious nature. Case summary A 47-year-old man presented with a multi-focal stroke suggestive of a cardioembolic source. Outpatient transoesophageal echocardiography (TOE) was concerning for vegetation or thrombus associated with his previous mitral valve repair. He remained clinically well, with no evidence of an inflammatory response and sterile blood cultures. Computed tomography–positron emission tomography (CT-PET) corroborated the TOE findings, however, given the atypical presentation, he was treated for valvular thrombus. Following discharge, he quickly re-presented with further embolic phenomena and underwent emergency mitral valve replacement. Intraoperative findings were consistent with prosthetic valve IE (PVE) and a 6-week course of antibiotics commenced. C. acnes was identified on molecular testing. Eighteen months later, he re-presented with further neurological symptoms. Early TOE and CT–PET were consistent with IE. Blood cultures grew C. acnes after prolonged incubation. Given the absence of surgical indications, he was managed medically, and the vegetation resolved without valvular dysfunction. He continues to be followed up in an outpatient setting. Discussion In patients presenting with multi-territory stroke, IE should be considered despite sterile blood cultures and absent inflammatory response. C. acnes is an increasingly recognized cause of PVE in this context, often requiring surgical intervention. A high index of suspicion and collaboration with an Endocarditis Team is therefore essential to diagnose and treat.