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Infective endocarditis (IE) poses a diagnostic challenge due to its diverse clinical presentations, especially among high-risk groups. Diagnosis relies on integrating clinical presentation, blood cultures and imaging findings. Advanced imaging techniques enhance diagnostic accuracy, particularly in complex cases. Treatment involves antimicrobial therapy and surgery in complicated cases, with early intervention crucial for optimal outcomes. Coordinated care by an Endocarditis Team ensures tailored treatment plans, prompt complication management and long-term monitoring after discharge. The authors present a case of subacute IE presenting initially with back pain in a patient with a complex medical history, highlighting diagnostic and management approaches.

BackgroundOur aim was to compare pediatric infective endocarditis (IE) with the clinical profile and outcomes of IE in adults.MethodsProspective multicenter registry in 31 Spanish hospitals including all patients with a diagnosis of IE from 2008 to 2020.ResultsA total of 5590 patients were included, 49 were <18 years (0.1%). Congenital heart disease (CHD) was present in 31 children and adolescents (63.2%). Right-sided location was more common in children/adolescents than in adults (46.9% vs. 6.3%, P < 0.001). Pediatric pulmonary IE was more frequent in patients with CHD (48.4%) than in those without (5.6%), P = 0.004. Staphylococcus aureus etiology tended to be more common in pediatric patients (32.7%) than in adults (22.3%), P = 0.082. Heart failure was less common in pediatric patients than in adults, due to the lower rate of heart failure in children/adolescents with CHD (9.6%) with respect to those without CHD (44.4%), P = 0.005. Inhospital mortality was high in both children, and adolescents and adults (16.3% vs. 25.9%; P = 0.126).ConclusionsMost IE cases in children and adolescents are seen in patients with CHD that have a more common right-sided location and a lower prevalence of heart failure than patients without CHD. IE in children and adolescents without CHD has a more similar profile to IE in adults.ImpactInfective endocarditis (IE) in children and adolescents is often seen in patients with congenital heart disease (CHD).Right-sided location is the most common in patients with CHD and heart failure is less common as a complication compared with patients without CHD.Infective endocarditis (IE) in children/adolescents without CHD has a more similar profile to IE in adults.In children/adolescents without CHD, locations were similar to adults, including a predominance of left-sided IE.Acute heart failure was the most frequent complication, seen mainly in adults, and in children/adolescents without CHD.

Despite improvements in medical and surgical therapies, infective endocarditis is associated with poor prognosis and remains a therapeutic challenge. Many factors affect the outcome of this serious disease, including virulence of the microorganism, characteristics of the patients, presence of underlying disease, delays in diagnosis and treatment, surgical indications, and timing of surgery. We review the strengths and limitations of present therapeutic strategies and propose future directions for better management of endocarditis according to the most recent research. Novel perspectives on the management of endocarditis are emerging and offer hope for decreasing the rate of residual deaths by accelerating the process of diagnosis and risk stratification, reducing delays in starting antimicrobial therapy, rapid transfer of high-risk patients to specialised medico-surgical centres, development of new surgical methods, and close long-term follow-up.

For over a century, acute ‘post-streptococcal glomerulonephritis’ (APSGN) was the prototypical form of bacterial infection-associated glomerulonephritis, typically occurring after resolution of infection and a distinct infection-free latent period. Other less common forms of infection-associated glomerulonephritides resulted from persistent bacteraemia in association with subacute bacterial endocarditis and shunt nephritis. However, a major paradigm shift in the epidemiology and bacteriology of infection-associated glomerulonephritides has occurred over the past few decades. The incidence of APSGN has sharply declined in the Western world, whereas the number of Staphylococcus infection-associated glomerulonephritis (SAGN) cases increased owing to a surge in drug-resistant Staphylococcus aureus infections, both in the hospital and community settings. These Staphylococcus infections range from superficial skin infections to deep-seated invasive infections such as endocarditis, which is on the rise among young adults owing to the ongoing intravenous drug use epidemic. SAGN is markedly different from APSGN in terms of its demographic profile, temporal association with active infection and disease outcomes. The diagnosis and management of SAGN is challenging because of the lack of unique histological features, the frequently occult nature of the underlying infection and the older age and co-morbidities in the affected patients. The emergence of multi-drug-resistant bacterial strains further complicates patient treatment.

PurposeS. aureus bacteremia (SAB) is a common and severe infection with high mortality and morbidity. The clinical relevance of the finding of concurrent S. aureus bacteriuria (SABU) is debated. The goal of this study was to analyze whether a concurrent SABU is associated with complicated SAB, infective endocarditis (IE) and mortality.MethodsWe conducted a retrospective cohort study, reviewing medical charts of all episodes of SAB in patients > 18 years in the region of Skåne, Sweden, between 1st of January and 31st of June 2020. Episodes where a concurrent urine culture was performed were included for analysis. An episode was considered as complicated SAB if there was either attributable mortality, recurrent infection, embolic stroke, or occurrence of a complicated focus of infection.ResultsDuring the study period, there were 279 episodes of SAB. 154 episodes met the eligibility criteria, of whom 37 (24%) had concurrent SABU. In 78 episodes (51%), the patients had a complicated SAB. There was a significantly lower proportion of complicated SAB for episodes with concurrent SABU (32%), compared to episodes without concurrent SABU (56%), p-value 0.014. Moreover, in the cohort there were 11 episodes (7.1%) of IE and a 30 days mortality rate of 16%, with no difference between the groups with or without SABU.ConclusionsThere is an association between concurrent SABU and a decreased risk for complicated SAB among patients with SAB. This study found no significant association between SABU and neither IE nor mortality for patients with SAB.

Abstract Background Staphylococcus aureus is a leading cause of bacteremia, yet there remains a significant knowledge gap in the identification of relevant biomarkers that predict clinical outcomes. Heterogeneity in the host response to invasive S. aureus infection suggests that specific biomarker signatures could be utilized to differentiate patients prone to severe disease, thereby facilitating earlier implementation of more aggressive therapies. Methods To further elucidate the inflammatory correlates of poor clinical outcomes in patients with S. aureus bacteremia, we evaluated the association between a panel of blood proteins at initial presentation of bacteremia and disease severity outcomes using 2 cohorts of patients with S. aureus bacteremia (n = 32 and n = 124). Results We identified 13 candidate proteins that were correlated with mortality and persistent bacteremia. Prognostic modeling identified interleukin (IL)-8 and CCL2 as the strongest individual predictors of mortality, with the combination of these biomarkers classifying fatal outcome with 89% sensitivity and 77% specificity (P < .0001). Baseline IL-17A levels were elevated in patients with persistent bacteremia (P < .0001), endovascular (P = .026) and metastatic tissue infections (P = .012). Conclusions These results demonstrate the potential utility of selected biomarkers to distinguish patients with the highest risk for treatment failure and bacteremia-related complications, providing a valuable tool for clinicians in the management of S. aureus bacteremia. Additionally, these biomarkers could identify patients with the greatest potential to benefit from novel therapies in clinical trials. Biomarkers identify S. aureus bacteremia patients at highest risk of treatment failure, with high circulating IL-17A levels at diagnosis prognostic for persistent bacteremia and chronic tissue infection foci while a combination of IL-8 and CCL2 identifies increased mortality risk.

Patients with aortic root abscesses experience increased morbidity and mortality compared to those without abscess in aortic valve infective endocarditis. The superior intervention for patients with aortic root abscess is not determined. This research investigates the degree to which increased morbidity and mortality of aortic root abscess, and to describe perioperative characteristics and outcomes of root operations versus root-sparing repairs of aortic root abscess. All patients who underwent surgical treatment of active aortic valve endocarditis between 2011 and 2022 at a single institution were reviewed, yielding 218 patients, of whom 64 had perivalvular abscess. Patients were treated with either simple (root-sparing) or complex (root replacement) techniques. Patients with abscess demonstrated significantly higher rates of previous cardiac surgery, redo endocarditis surgery, aortocavitary fistula, heart block, and prosthetic valve endocarditis. One quarter of abscesses were not detected on preoperative imaging. Presence of abscess was a significant predictor of operative mortality. Prosthetic valve endocarditis was a significant predictor of complex repair in patients with abscess. Five-year survival was similar between simple and complex repair groups in patients with abscess. Aortic root abscess confers significant morbidity and mortality, and measures should be taken to ensure early detection and treatment of this condition.

Background Infective endocarditis (IE) in children with pre-existing heart conditions is a life-threatening disease entity associated with significant morbidity and mortality. In our cardiac setting, the management outcomes of children with IE are not well documented. We therefore aimed to document the clinical profile and treatment outcomes of children with IE attended at the Jakaya Kikwete Cardiac Institute (JKCI). Methods This was a hospital-based cross-sectional study with longitudinal follow-up conducted among children with IE diagnosed by Modified Duke’s Criteria at the JKCI from November 2021 to November 2023. A structured questionnaire was used to collect patients’ socio-demographic and clinical data. Results During the study period, 1,546 children were admitted to the JKCI. A total of 30 children with IE were enrolled, of these half ( n  = 16, 53%) were aged 10 to 18 years, with a median of 10 yrs (Inter quartile range, IQR: 6.5–12.2 yrs). Twelve children (40%) and nearly half ( n  = 14, 47%) had fever and used antibiotic therapy respectively. Majority of participants had anaemia ( n  = 26, 87%) and heart failure ( n  = 21, 70%). Nine children (30%) had positive blood cultures and S. aureus was the most frequently isolated organism ( n  = 7). Ten patients (33%) developed acute kidney injury (AKI), and eleven (37%) children died during the hospital stay. Conclusion In our setting, in-hospital mortality due to IE among children with heart diseases is high. Heart failure and anaemia were the common presentations of IE. Furthermore, AKI was observed to be the leading in-hospital non-cardiac complication.

Background. The NOVA score is a recently developed diagnostic tool used to identify patients with increased risk of infective endocarditis (IE) among patients with Enterococcus faecalis bacteremia. We aimed to validate the NOVA score and to identify risk factors for IE. Methods. From 1 January 2010 to 31 December 2013, we included 647 consecutive patients with E. faecalis bacteremia. The NOVA score was used in a slightly adapted form; 2/2 positive blood cultures resulted in 5 points, unknown origin of infection in 4 points, prior valve disease in 2 points, and heart murmur in 1 point. Results. IE was diagnosed in 78 patients (12%). Monomicrobial E. faecalis bacteremia (hazard ratio [HR], 3.60; 95% confidence interval [CI], 1.6–8.0), prosthetic heart valve (HR, 6.2; 95% CI, 3.8–10.1), male sex (HR, 2.0; 95% CI, 1.1–3.8), and community acquisition (HR, 1.8; 95% CI, 1.1–2.9) were independently associated with IE. The adapted NOVA score was applied in the 240 patients examined by echocardiography. A low score (<4) was found in 40 patients (17%), implying a low likelihood of IE. Of the 78 patients with IE, 76 had a high score (≥4), resulting in a sensitivity of 97% specificity of 23%, a negative predictive value of 95%, and a positive predictive value of 38%. Conclusions. Monomicrobial E. faecalis bacteremia, community acquisition, prosthetic heart valve, and male sex are associated with increased risk of IE. In our retrospective cohort, the adapted NOVA score performed well, suggesting that it could be useful in guiding clinical decisions.

ObjectiveThe best strategy to manage patients with left-sided infective endocarditis (IE) and intermediate-length vegetations (10–15 mm) remains uncertain. We aimed to evaluate the role of surgery in patients with intermediate-length vegetations and no other European Society of Cardiology guidelines-approved surgical indication.MethodsWe retrospectively enrolled 638 consecutive patients admitted to three academic centres (Amiens, Marseille and Florence University Hospitals) between 2012 and 2022 for left-sided definite IE (native or prosthetic) with intermediate-length vegetations (10–15 mm). We compared four clinical groups: medically (n=50) or surgically (n=345) treated complicated IE, medically (n=194) or surgically (n=49) treated uncomplicated IE.ResultsMean age was 67±14 years. Women were 182 (28.6%). The rate of embolic events on admission was 40% in medically treated and 61% in surgically treated complicated IE, 31% in medically treated and 26% in surgically treated uncomplicated IE. The analysis of all-cause mortality showed the lowest 5-year survival rate for medically treated complicated IE (53.7%). We found a similar 5-year survival rate for surgically treated complicated IE (71.4%) and medically treated uncomplicated IE (68.4%). The highest 5-year survival rate was observed in surgically treated uncomplicated IE group (82.4%, log-rank p<0.001). The analysis of the propensity score-matched cohort estimated an HR of 0.23 for uncomplicated IE treated surgically compared with medical therapy (p=0.005, 95% CI: 0.079 to 0.656).ConclusionsOur results suggest that surgery is associated with lower all-cause mortality than medical therapy in patients with uncomplicated left-sided IE with intermediate-length vegetations even in the absence of other guideline-based indications.