Diagnosis, treatment and prevention of infective endocarditis: Turkish consensus report-2019 [İnfektif endokarditin tanısı, tedavisi ve önlenmesi: Ulusal uzlaşı raporu-2019]

Infective endocarditis (IE) is a rare but still important as an infectious disease due to high rate of morbidity and substantial mortality. Although IE is not a notifiable disease in Turkey, and an incidence study has not been performed, the incidence may be higher than that in the developed countries due to frequent predisposing cardiac conditions and higher rates of nosocomial bacteremia, which may lead to IE in risk groups. IE generally affects the elderly in developed countries but it is frequently encountered among young individuals in Turkey. In order to reduce mortality and morbidity, it is critical to diagnose IE, to determine the causative agent, and to start treatment rapidly. Most patients cannot be diagnosed at the first visit, about half can be diagnosed after 3 months, and the disease often goes unnoticed. In patients diagnosed with IE, the rate of the identification of a causative organism is significantly lower in Turkey than that in developed countries. Some important microbiological diagnostic tests are not performed in most centers and several antimicrobials that are recommended as the first option for the treatment particularly antistaphylococcal penicillins, are unavailable in Turkey. These problems necessitate reviewing the epidemiological, laboratory, and clinical characteristics of IE in our country, as well as the current information about its diagnosis, treatment, and prevention together with local data. The diagnosis and treatment processes of IE should be standardized at every stage so that the management can be conducted in a setting in which physicians of various specialties are involved and is consistent with the current recommendations. The Study Group for Infective Endocarditis and Other Cardiovascular Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases called for the collaboration of the relevant specialist organizations to establish a consensus report on the diagnosis, treatment, and prevention of IE in the context of current information and local data in Turkey. © 2020 Turkish Society of Cardiology

Methicillin-Resistant Staphylococcus aureus Infection: An Independent Risk Factor for Mortality in Patients with Poststernotomy Mediastinitis

Objective: The mortality rate of patients with poststernotomy mediastinitis remains very high. The aim of this study was to identify the risk factors associated with mortality in these patients. Subjects and Methods: Surveillance of sternal surgicalsite infections including mediastinitis was carried out for adult patients undergoing a sternotomy between 2004 and 2012. Criteria from the US Centers for Disease Control and Prevention were used to make the diagnosis. All data on patients with a diagnosis of mediastinitis who were included in the study and on mortality risk factors were obtained from the hospital database and then analyzed using SPPS 16.0 for Windows. Results: Of the 19,767 patients undergoing open heart surgery, 117 (0.39%) had poststernotomy mediastinitis; 32% of these 117 died. The independent risk factors for mortality were methicillin-resistant Staphylococcus aureus (MRSA) [odds ratio (OR) 12.11 and 95% confidence interval (CI) 3.15-46.47], intensive-care unit stays >48 h after the first operation OR 11.21 and 95% CI 3.24-38.84) and surgery that included valve replacement (OR 6.2 and 95% CI 1.44-27.13). The mortality rate decreased significantly, dropping from 38% (34/89) between 2004 and 2008 to 14% (4/28) between 2009 and 2012 (p = 0.018). Conclusion: In this study, elimination of MRSA from the hospital setting decreased the rate of mortality in patients with poststernotomy mediastinitis. (C) 2014 S. Karger AG, Base

Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases

Objective: In order to define the current characteristics of infective endocarditis (IE) in Turkey, we evaluated IE cases over a 14-year period in a tertiary referral hospital. Methods: All adult patients who were hospitalized in our hospital with a diagnosis of IE between 2000 and 2013 were included in the study. Modified Duke criteria were used for diagnosis. The Chi-square test, Student's t-test, Mann–Whitney U-test, Cox and logistic regression analysis were used for the statistical analysis. Results: There were 325 IE cases during the study period. The mean age of the patients was 47 years. Causative microorganisms were identified in 253 patients (77.8%) and included staphylococci (36%), streptococci (19%), enterococci (7%), and Brucella spp (5%). A streptococcal aetiology was associated with younger age (1.2 mg/dl (OR 2.15). Older age (>50 year) (OR 3.93), patients with perivalvular abscess (OR 9.18), being on dialysis (OR 6.22), and late prosthetic valve endocarditis (OR 3.15) were independent risk factors for enterococcal IE. Independent risk factors for mortality in IE cases were the following: being on dialysis (hazard ratio (HR) 4.13), presence of coronary artery heart disease (HR 2.09), central nervous system emboli (HR 2.33), and congestive heart failure (HR 2.15). Higher haemoglobin (HR 0.87) and platelet (HR 0.996) levels and surgical interventions for IE (HR 0. 33) were found to be protective factors against mortality. Conclusions: In Turkey, IE occurs in relatively young patients and Brucella spp should always be taken into consideration as a cause of this infection. We should first consider streptococci as the causative agents of IE in young patients, those with CRHD or congenital heart valve disease, and cases of community-acquired IE. Staphylococci should be considered first in the case of pacemaker lead IE, when there are high levels of creatinine, and in cases of healthcare-associated IE. Enterococci could be the most probable causative agent of IE particularly in patients aged >50 years, those on dialysis, those with late prosthetic valve IE, and those with a perivalvular abscess. The early diagnosis and treatment of IE before complications develop is crucial because the mortality rate is high among cases with serious complications. The prevention of bacteraemia with the measures available among chronic haemodialysis patients should be a priority because of the higher mortality rate of subsequent IE among this group of patients

Infective endocarditis in Turkey: aetiology, clinical features, and analysis of risk factors for mortality in 325 cases

Objective: In order to define the current characteristics of infective endocarditis (LE) in Turkey, we evaluated LE cases over a 14-year period in a tertiary referral hospital

Radiolabelled proteomics to determine differential functioning of Accumulibacter during the anaerobic and aerobic phases of a bioreactor operating for enhanced biological phosphorus removal

Proteins synthesized by the mixed microbial community of two sequencing batch reactors run for enhanced biological phosphorus removal (EBPR) during aerobic and anaerobic reactor phases were compared, using mass spectrometry-based proteomics and radiolabelling. Both sludges were dominated by polyphosphate-accumulating organisms belonging to Candidatis Accumulibacter and the majority of proteins identified matched closest to these bacteria. Enzymes from the Embden–Meyerhof–Parnas pathway were identified, suggesting this is the major glycolytic pathway for these Accumulibacter populations. Enhanced aerobic synthesis of glyoxylate cycle enzymes suggests this cycle is important during the aerobic phase of EBPR. In one sludge, several TCA cycle enzymes showed enhanced aerobic synthesis, suggesting this cycle is unimportant anaerobically. The second sludge showed enhanced synthesis of TCA cycle enzymes under anaerobic conditions, suggesting full or partial TCA cycle operation anaerobically. A phylogenetic analysis of Accumulibacter polyphosphate kinase genes from each sludge demonstrated different Accumulibacter populations dominated the two sludges. Thus, TCA cycle activity differences may be due to Accumulibacter strain differences. The major fatty acids present in Accumulibacter-dominated sludge include palmitic, hexadecenoic and cis-vaccenic acid and fatty acid content increased by approximately 20% during the anaerobic phase. We hypothesize that this is associated with increased anaerobic phospholipid membrane biosynthesis, to accommodate intracellular polyhydroxyalkanoate granules

Diagnosis, Treatment And Prevention Of Infective Endocarditis: Turkish Consensus Report

Although infective endocarditis (IE) is rare, it is still important as an infectious disease because of the resulting morbidity and substantial mortality rates. Epidemiological studies in developed countries have shown that the incidence of IE has been approximately 6/100 000 in recent years and it is on the fourth rank among the most life-threatening infectious diseases after sepsis, pneumonia and intraabdominal infections. Although IE is not a reportable disease in Turkey, and an incidence study was not performed, its incidence may be expected to be higher due to both more frequent presence of predisposing cardiac conditions and higher rates of nosocomial bacteremia which may lead to IE in risk groups. Additionally, while IE generally affects elderly people in developed countries it still affects young people in Turkey. In order to reduce the mortality and morbidity, it is critical to diagnose the 1E, to determine the causative agent and to start treatment rapidly. However, most of the patients cannot be diagnosed in their first visits, about half of them can be diagnosed after 3 months, and the disease often goes unnoticed. In patients diagnosed as IE, the rate of identification of causative organisms is more than 90% in developed countries, while it is around 60% in Turkey. Furthermore, some important microbiological diagnostic tests are not performed in most of the centers. Some antimicrobials that are recommended as the first option for treatment of IE, particularly antistaphylococcal penicillins, are unavailable in Turkey. These problems necessitate to review the epidemiological, laboratory and clinical characteristics of IE in the country, as well as the current information about its diagnosis, treatment and prevention together with local data. Patients with IE can be followed by physicians in many specialties. Diagnosis and treatment processes of IE should be standardized at every stage so that management of IE, a setting in which many physicians are involved, can always be in line with current recommendations. From this point of view, Study Group for Infective Endocarditis and Other Cardiovascular Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases has called for collaboration of the relevant specialist organizations to establish a consensus report on the diagnosis, treatment and prevention of IE in the light of current information and local data in Turkey. In the periodical meetings of the assigned representatives from all the parties, various questions were identified. Upon reviewing related literature and international guidelines, these questions were provided with consensus answers. Several of the answers provided in the report are listed below: [1] IE is more frequent in patients with a previous episode of IE, a valvular heart disease, a congenital heart disease, any intracardiac prosthetic material, an intravenous drug addiction, chronic hemodialysis treatment, solid organ and hematopoietic stem cell transplantation as compared with normal population. [2] The most frequent causative organisms are Staphylococcus aureus, streptococci, coagulase-negative staphylococci, and enterococci, respectively, both in Turkey and globally. Brucella spp. is the fifth common causative agent of IE in Turkey. [3] The echocardiography is the imaging modality of choice to define cardiac lesions in patients with suspected IE. Both transthoracic and transesophageal echocardiography are generally necessary in almost all patients. Both are inconclusive approximately in 15% of total IE cases whereas the percentage is up to 30% in patients with intracardiac prosthetic devices. In these instances, multi-slice (MS) computed tomography (CT) should be the imaging modality in patients with native valve IE, whereas MS-CT or radiolabelled leukocyte scintigraphy with single-photon emission tomography/CT should be choosen for patients who have prosthetic valve IE within the first 3 months of surgery, and MS-CT or positron-emission tomography/CT should be chosen for patients with prosthetic valve IE after 3 months of surgery. [4] Blood cultures should be taken without any delay to catch-up the febrile period as 3 sets with 30-minute intervals (3 aerobic and 3 anaerobic bottles, totally 6 bottles) in patients with suspected IE. Each set, comprised of 1 aerobic and 1 anaerobic bottle, should be inoculated with 18-20 ml of blood (9 -10 ml blood per bottle). Totally 60 ml of blood should be taken from one patient with suspected IE. Two sets of control blood cultures should be repeated in every 48 hours after initiation of therapy in order to show blood sterility. If causative organism do not grow in the usual blood culture bottles, additional three mycobacterial blood culture bottles should be inoculated in patients with suspected prosthetic valve IE and who had a cardiac surgery in the last decade. [5] The excised valvular tissue from patients with suspected IE should be evaluated both microbiologically and histopathologically.[6] First of all, Wright agglutination test (if negative, by adding Coombs' serum) and indirect fluorescent antibody (IFA) test to investigate Coxiella burnetii phase I IgG antibodies should be done in culture-negative patients. If these two tests are negative, IgG antibodies for Bartonella spp., Legionella spp., Chlamydia spp., and Mycoplasma spp. should be tested respectively and preferably by IFA test. [7] Multiplex polymerase chain reaction (PCR) tests should be used to identify the pathogen in whole blood in a culturenegative patient who has received previous antibiotic therapy. If the blood cultures are negative in a patient who has not received previous antibiotic therapy, PCR tests for 16S rRNA gene analysis and Tropheryma whipplei should be performed on the resected valve obtained during surgery. [8] Histopathological examination of resected valvular tissue in patients with suspected IE give valuable information about the activation and degree of the inflammation. Moreover, histopathological examination with appropriate routine and immunohistochemical staining, aid to identify especially intracellular pathogens like C. burnetii, Bartonella spp. and T. whipplei in blood culture-negative patients. [9] Bactericidal agents given parenterally for long duration is the general principle of antimicrobial treatment of IE. The pathogenic organism, presence of prosthetic material and duration of symptoms specifies the duration of treatment. The therapy duration is generally 4-6 weeks for native valve IE and >6 weeks for prosthetic valve IE. [10] As the efficacy and feasibility of oral antimicrobial choices of left-sided IE are not well defined in Turkey and it is related with substantial mortality, parenteral route should be preferred for the complete duration of antimicrobial treatment of left-sided IE in Turkey. In case of unavailability of intravenous access or outpatient parenteral antibiotic therapy, oral agents may be feasible to complete the therapy duration in stable patients with uncomplicated native valve IE due to drug-susceptible viridans streptococci, provided that initial two weeks should be completed parenterally, and the patient should give an informed consent after notifying all possible risks, and regular post-discharge follow-up should be possible. The decision for oral maintenance therapy has to be given by the IE team. [11] The appropriate antimicrobials should be initiated without any delay as it reduces not only the risk of an embolic event in patients with either acute or subacute IE, but also decreases the mortality associated with sepsis in acute IE. Therefore, the empirical antimicrobials should be promptly initiated after blood cultures are taken. [12] Ampicillin-sulbactam +/- gentamicin can be initiated empirically in the treatment of community-acquired, both acute and subacute types of native and late prosthetic valve IE in adults whereas either vancomycin + ampicillin-sulbactam or ceftriaxone +/- gentamicin can be the choice for acute types. Vancomycin + cefepime +/- gentamicin combination can be initiated empirically in the treatment of nosocomial native, early and late prosthetic valve IE in adults. Gentamicin should be avoided initially in patients with impaired renal function. Rifampin can be added to initial empirical treatment of early prosthetic valve IE. Daptomycin alone is not a drug of choice for initial empirical treatment of IE because of its suboptimal efficacy for streptococci and enterococci in which resistance can easily develop during therapy.WoSScopu

Consensus Report on Diagnosis, Treatment and Prevention of Infective Endocarditis by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Clinical Microbiology and Infectious Diseases (KLIMIK), Turkish Society of Cardiology (TSC), Turkish Society of Nuclear Medicine (TSNM), Turkish Society of Radiology (TSR), Turkish Dental Association (TDA) and Federation of Turkish Pathology Societies (TURKPATH) Cardiovascular System Study Group

Infective endocarditis (IE) is rare, but associated with significant morbidity and mortality rates. Estimates of the incidence of IE in Turkey are compromised by the absence of population-based prospective studies. Due to the frequent presence of predisposing cardiac conditions and higher rates of nosocomial bacteremia in high-risk groups, the incidence of IE is expected to be higher in Turkey. Additionally, while IE generally affects older people in developed countries, it still affects young people in Turkey. In order to reduce the mortality and morbidity, it is critical to diagnose the IE to determine the causative agent and to start treatment rapidly. However, most of the patients cannot be diagnosed in their first visits, about half of them can be diagnosed after three months, and the disease often goes unnoticed. In patients diagnosed with IE, the rate of identification of causative organisms is significantly lower in Turkey than in developed countries. Furthermore, most of the centers do not perform some essential microbiological diagnostic tests as a routine practice. Some antimicrobials that are recommended as the first-line of treatment for IE, particularly antistaphylococcal penicillins, are not available in Turkey. These problems necessitate reviewing the epidemiological, laboratory, and clinical characteristics of IE in our country, as well as the current information about its diagnosis, treatment, and prevention together with local data. Physicians can follow patients with IE in many specialties. Diagnosis and treatment processes of IE should be standardized at every stage so that management of IE, a setting in which many physicians are involved, can always be in line with current recommendations. Study Group for Infective Endocarditis and Other Cardiovascular Infections of the Turkish Society of Clinical Microbiology and Infectious Diseases has called for collaboration of the relevant specialist organizations to establish a consensus report on the diagnosis, treatment, and prevention of IE in the light of current information and local data in Turkey