Predictors of mortality in solid-organ transplant recipients with bloodstream infections due to carbapenemase-producing Enterobacterales: the impact of cytomegalovirus disease and lymphopenia

Treatment of carbapenemase-producing Enterobacterales bloodstream infections (CPE-BSI) in solid-organ transplant recipients (SOT) is challenging. The objective of this study was to develop a specific score to predict mortality in SOT recipients with CPE-BSI. A multinational, retrospective (2004-2016) cohort study (INCREMENT-SOT, ClinicalTrials.gov NCT02852902) was performed. The main outcome variable was 30-day all-cause mortality. The INCREMENT-SOT-CPE score was developed using logistic regression. The global cohort included 216 patients. The final logistic regression model included the following variables: INCREMENT-CPE mortality score ≥8 (8 points), no source control (3 points), inappropriate empirical therapy (2 points), cytomegalovirus disease (7 points), lymphopenia (4 points), and the interaction between INCREMENT-CPE score ≥8 and CMV disease (minus 7 points). This score showed an area under the receiver operating characteristic curve of 0.82 (95% CI 0.76-0.88) and classified patients into three strata: 0-7 (low mortality), 8-11 (high mortality) and 12-17 (very-high mortality). We performed a stratified analysis of the effect of monotherapy versus combination therapy among 165 patients who received appropriate therapy. Monotherapy was associated with higher mortality only in the very-high (adjusted HR 2.82, 95% CI 1.13-7.06, P=0.03) and high (HR 9.93, 95% CI 2.08-47.40, P=0.004) mortality risk strata. A score-based algorithm is provided for therapy guidance

Infective Endocarditis in Patients on Chronic Hemodialysis

295sinoneBackground: Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD). Objectives: This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients. Methods: Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression. Results: A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non–HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p < 0.001). Cardiac surgery was less frequently performed among HD patients (30.6% vs. 46.2%; p < 0.001), whereas relapses were higher (9.4% vs. 2.7%; p < 0.001). Risk factors for 6-month mortality included Charlson score (hazard ratio [HR]: 1.26; 95% confidence interval [CI]: 1.11 to 1.44; p = 0.001), CNS emboli and other emboli (HR: 3.11; 95% CI: 1.84 to 5.27; p < 0.001; and HR: 1.73; 95% CI: 1.02 to 2.93; p = 0.04, respectively), persistent bacteremia (HR: 1.79; 95% CI: 1.11 to 2.88; p = 0.02), and acute onset heart failure (HR: 2.37; 95% CI: 1.49 to 3.78; p < 0.001). Conclusions: HD-IE is a health care–associated infection chiefly caused by S. aureus, with increasing rates of enterococcal IE. Mortality and relapses are very high and significantly larger than in non–HD-IE patients, whereas cardiac surgery is less frequently performed.nonePericas J.M.; Llopis J.; Jimenez-Exposito M.J.; Kourany W.M.; Almirante B.; Carosi G.; Durante-Mangoni E.; Fortes C.Q.; Giannitsioti E.; Lerakis S.; Montagna-Mella R.; Ambrosioni J.; Tan R.-S.; Mestres C.A.; Wray D.; Pachirat O.; Moreno A.; Chu V.H.; de Lazzari E.; Fowler V.G.; Miro J.M.; Clara L.; Sanchez M.; Casabe J.; Cortes C.; Nacinovich F.; Oses P.F.; Ronderos R.; Sucari A.; Thierer J.; Altclas J.; Kogan S.; Spelman D.; Athan E.; Harris O.; Kennedy K.; Tan R.; Gordon D.; Papanicolas L.; Korman T.; Kotsanas D.; Dever R.; Jones P.; Konecny P.; Lawrence R.; Rees D.; Ryan S.; Feneley M.P.; Harkness J.; Post J.; Reinbott P.; Gattringer R.; Wiesbauer F.; Andrade A.R.; Passos de Brito A.C.; Guimaraes A.C.; Grinberg M.; Mansur A.J.; Siciliano R.F.; Varejao Strabelli T.M.; Campos Vieira M.L.; de Medeiros Tranchesi R.A.; Paiva M.G.; de Oliveira Ramos A.; Weksler C.; Ferraiuoli G.; Golebiovski W.; Lamas C.; Karlowsky J.A.; Keynan Y.; Morris A.M.; Rubinstein E.; Jones S.B.; Garcia P.; Cereceda M.; Fica A.; Mella R.M.; Fernandez R.; Franco L.; Gonzalez J.; Jaramillo A.N.; Barsic B.; Bukovski S.; Krajinovic V.; Pangercic A.; Rudez I.; Vincelj J.; Freiberger T.; Pol J.; Zaloudikova B.; Ashour Z.; El Kholy A.; Mishaal M.; Osama D.; Rizk H.; Aissa N.; Alauzet C.; Alla F.; Campagnac C.C.; Doco-Lecompte T.; Selton-Suty C.; Casalta J.-P.; Fournier P.-E.; Habib G.; Raoult D.; Thuny F.; Delahaye F.; Delahaye A.; Vandenesch F.; Donal E.; Donnio P.Y.; Flecher E.; Michelet C.; Revest M.; Tattevin P.; Chevalier F.; Jeu A.; Remadi J.P.; Rusinaru D.; Tribouilloy C.; Bernard Y.; Chirouze C.; Hoen B.; Leroy J.; Plesiat P.; Naber C.; Neuerburg C.; Mazaheri B.; Sophia Athanasia C.N.; Deliolanis I.; Giamarellou H.; Thomas T.; Mylona E.; Paniara O.; Papanicolaou K.; Pyros J.; Skoutelis A.; Papanikolaou K.; Sharma G.; Francis J.; Nair L.; Thomas V.; Venugopal K.; Hannan M.M.; Hurley J.P.; Wanounou M.; Gilon D.; Israel S.; Korem M.; Strahilevitz J.; Iossa D.; Orlando S.; Ursi M.P.; Pafundi P.C.; D'Amico F.; Bernardo M.; Cuccurullo S.; Dialetto G.; Covino F.E.; Manduca S.; Della Corte A.; De Feo M.; Tripodi M.F.; Cecchi E.; De Rosa F.; Forno D.; Imazio M.; Trinchero R.; Grossi P.; Lattanzio M.; Toniolo A.; Goglio A.; Raglio A.; Ravasio V.; Rizzi M.; Suter F.; Magri S.; Signorini L.; Kanafani Z.; Kanj S.S.; Sharif-Yakan A.; Abidin I.; Tamin S.S.; Martinez E.R.; Soto Nieto G.I.; van der Meer J.T.M.; Chambers S.; Holland D.; Morris A.; Raymond N.; Read K.; Murdoch D.R.; Dragulescu S.; Ionac A.; Mornos C.; Butkevich O.M.; Chipigina N.; Kirill O.; Vadim K.; Vinogradova T.; Edathodu J.; Halim M.; Liew Y.-Y.; Lejko-Zupanc T.; Logar M.; Mueller-Premru M.; Commerford P.; Commerford A.; Deetlefs E.; Hansa C.; Ntsekhe M.; Almela M.; Azqueta M.; Brunet M.; Castro P.; Falces C.; Fuster D.; Fita G.; Garcia- de- la- Maria C.; Garcia-Gonzalez J.; Gatell J.M.; Marco F.; Miro J.M.; Ortiz J.; Ninot S.; Pare J.C.; Pericas J.M.; Quintana E.; Ramirez J.; Rovira I.; Sandoval E.; Sitges M.; Tellez A.; Tolosana J.M.; Vidal B.; Vila J.; Anguera I.; Font B.; Guma J.R.; Bermejo J.; Bouza E.; Garcia Fernandez M.A.; Gonzalez-Ramallo V.; Marin M.; Munoz P.; Pedromingo M.; Roda J.; Rodriguez-Creixems M.; Solis J.; Fernandez-Hidalgo N.; Tornos P.; de Alarcon A.; Parra R.; Alestig E.; Johansson M.; Olaison L.; Snygg-Martin U.; Pachirat P.; Pussadhamma B.; Senthong V.; Casey A.; Elliott T.; Lambert P.; Watkin R.; Eyton C.; Klein J.L.; Bradley S.; Kauffman C.; Bedimo R.; Corey G.R.; Crowley A.L.; Douglas P.; Drew L.; Holland T.; Lalani T.; Mudrick D.; Samad Z.; Sexton D.; Stryjewski M.; Wang A.; Woods C.W.; Cantey R.; Steed L.; Dickerman S.A.; Bonilla H.; DiPersio J.; Salstrom S.-J.; Baddley J.; Patel M.; Peterson G.; Stancoven A.; Levine D.; Riddle J.; Rybak M.; Cabell C.H.Pericas, J. M.; Llopis, J.; Jimenez-Exposito, M. J.; Kourany, W. M.; Almirante, B.; Carosi, G.; Durante-Mangoni, E.; Fortes, C. Q.; Giannitsioti, E.; Lerakis, S.; Montagna-Mella, R.; Ambrosioni, J.; Tan, R. -S.; Mestres, C. A.; Wray, D.; Pachirat, O.; Moreno, A.; Chu, V. H.; de Lazzari, E.; Fowler, V. G.; Miro, J. M.; Clara, L.; Sanchez, M.; Casabe, J.; Cortes, C.; Nacinovich, F.; Oses, P. F.; Ronderos, R.; Sucari, A.; Thierer, J.; Altclas, J.; Kogan, S.; Spelman, D.; Athan, E.; Harris, O.; Kennedy, K.; Tan, R.; Gordon, D.; Papanicolas, L.; Korman, T.; Kotsanas, D.; Dever, R.; Jones, P.; Konecny, P.; Lawrence, R.; Rees, D.; Ryan, S.; Feneley, M. P.; Harkness, J.; Post, J.; Reinbott, P.; Gattringer, R.; Wiesbauer, F.; Andrade, A. R.; Passos de Brito, A. C.; Guimaraes, A. C.; Grinberg, M.; Mansur, A. J.; Siciliano, R. F.; Varejao Strabelli, T. M.; Campos Vieira, M. L.; de Medeiros Tranchesi, R. A.; Paiva, M. G.; de Oliveira Ramos, A.; Weksler, C.; Ferraiuoli, G.; Golebiovski, W.; Lamas, C.; Karlowsky, J. A.; Keynan, Y.; Morris, A. M.; Rubinstein, E.; Jones, S. B.; Garcia, P.; Cereceda, M.; Fica, A.; Mella, R. M.; Fernandez, R.; Franco, L.; Gonzalez, J.; Jaramillo, A. N.; Barsic, B.; Bukovski, S.; Krajinovic, V.; Pangercic, A.; Rudez, I.; Vincelj, J.; Freiberger, T.; Pol, J.; Zaloudikova, B.; Ashour, Z.; El Kholy, A.; Mishaal, M.; Osama, D.; Rizk, H.; Aissa, N.; Alauzet, C.; Alla, F.; Campagnac, C. C.; Doco-Lecompte, T.; Selton-Suty, C.; Casalta, J. -P.; Fournier, P. -E.; Habib, G.; Raoult, D.; Thuny, F.; Delahaye, F.; Delahaye, A.; Vandenesch, F.; Donal, E.; Donnio, P. Y.; Flecher, E.; Michelet, C.; Revest, M.; Tattevin, P.; Chevalier, F.; Jeu, A.; Remadi, J. P.; Rusinaru, D.; Tribouilloy, C.; Bernard, Y.; Chirouze, C.; Hoen, B.; Leroy, J.; Plesiat, P.; Naber, C.; Neuerburg, C.; Mazaheri, B.; Sophia Athanasia, C. N.; Deliolanis, I.; Giamarellou, H.; Thomas, T.; Mylona, E.; Paniara, O.; Papanicolaou, K.; Pyros, J.; Skoutelis, A.; Papanikolaou, K.; Sharma, G.; Francis, J.; Nair, L.; Thomas, V.; Venugopal, K.; Hannan, M. M.; Hurley, J. P.; Wanounou, M.; Gilon, D.; Israel, S.; Korem, M.; Strahilevitz, J.; Iossa, D.; Orlando, S.; Ursi, M. P.; Pafundi, P. C.; D'Amico, F.; Bernardo, M.; Cuccurullo, S.; Dialetto, G.; Covino, F. E.; Manduca, S.; Della Corte, A.; De Feo, M.; Tripodi, M. F.; Cecchi, E.; De Rosa, F.; Forno, D.; Imazio, M.; Trinchero, R.; Grossi, P.; Lattanzio, M.; Toniolo, A.; Goglio, A.; Raglio, A.; Ravasio, V.; Rizzi, M.; Suter, F.; Magri, S.; Signorini, L.; Kanafani, Z.; Kanj, S. S.; Sharif-Yakan, A.; Abidin, I.; Tamin, S. S.; Martinez, E. R.; Soto Nieto, G. I.; van der Meer, J. T. M.; Chambers, S.; Holland, D.; Morris, A.; Raymond, N.; Read, K.; Murdoch, D. R.; Dragulescu, S.; Ionac, A.; Mornos, C.; Butkevich, O. M.; Chipigina, N.; Kirill, O.; Vadim, K.; Vinogradova, T.; Edathodu, J.; Halim, M.; Liew, Y. -Y.; Lejko-Zupanc, T.; Logar, M.; Mueller-Premru, M.; Commerford, P.; Commerford, A.; Deetlefs, E.; Hansa, C.; Ntsekhe, M.; Almela, M.; Azqueta, M.; Brunet, M.; Castro, P.; Falces, C.; Fuster, D.; Fita, G.; Garcia- de- la- Maria, C.; Garcia-Gonzalez, J.; Gatell, J. M.; Marco, F.; Miro, J. M.; Ortiz, J.; Ninot, S.; Pare, J. C.; Pericas, J. M.; Quintana, E.; Ramirez, J.; Rovira, I.; Sandoval, E.; Sitges, M.; Tellez, A.; Tolosana, J. M.; Vidal, B.; Vila, J.; Anguera, I.; Font, B.; Guma, J. R.; Bermejo, J.; Bouza, E.; Garcia Fernandez, M. A.; Gonzalez-Ramallo, V.; Marin, M.; Munoz, P.; Pedromingo, M.; Roda, J.; Rodriguez-Creixems, M.; Solis, J.; Fernandez-Hidalgo, N.; Tornos, P.; de Alarcon, A.; Parra, R.; Alestig, E.; Johansson, M.; Olaison, L.; Snygg-Martin, U.; Pachirat, P.; Pussadhamma, B.; Senthong, V.; Casey, A.; Elliott, T.; Lambert, P.; Watkin, R.; Eyton, C.; Klein, J. L.; Bradley, S.; Kauffman, C.; Bedimo, R.; Corey, G. R.; Crowley, A. L.; Douglas, P.; Drew, L.; Holland, T.; Lalani, T.; Mudrick, D.; Samad, Z.; Sexton, D.; Stryjewski, M.; Wang, A.; Woods, C. W.; Cantey, R.; Steed, L.; Dickerman, S. A.; Bonilla, H.; Dipersio, J.; Salstrom, S. -J.; Baddley, J.; Patel, M.; Peterson, G.; Stancoven, A.; Levine, D.; Riddle, J.; Rybak, M.; Cabell, C. H

Impact of early valve surgery on outcome of staphylococcus aureus prosthetic valve infective endocarditis: Analysis in the international collaboration of endocarditis-prospective cohort study

Background. The impact of early valve surgery (EVS) on the outcome of Staphylococcus aureus (SA) prosthetic valve infective endocarditis (PVIE) is unresolved. The objective of this study was to evaluate the association between EVS, performed within the first 60 days of hospitalization, and outcome of SA PVIE within the International Collaboration on Endocarditis-Prospective Cohort Study. Methods. Participants were enrolled between June 2000 and December 2006. Cox proportional hazards modeling that included surgery as a time-dependent covariate and propensity adjustment for likelihood to receive cardiac surgery was used to evaluate the impact of EVS and 1-year all-cause mortality on patients with definite left-sided S. aureus PVIE and no history of injection drug use. Results. EVS was performed in 74 of the 168 (44.3%) patients. One-year mortality was significantly higher among patients with S. aureus PVIE than in patients with non-S. aureus PVIE (48.2% vs 32.9%; P = .003). Staphylococcus aureus PVIE patients who underwent EVS had a significantly lower 1-year mortality rate (33.8% vs 59.1%; P = .001). In multivariate, propensity-adjusted models, EVS was not associated with 1-year mortality (risk ratio, 0.67 [95% confidence interval, .39-1.15]; P = .15). Conclusions. In this prospective, multinational cohort of patients with S. aureus PVIE, EVS was not associated with reduced 1-year mortality. The decision to pursue EVS should be individualized for each patient, based upon infection-specific characteristics rather than solely upon the microbiology of the infection causing PVIE

Impact of early valve surgery on outcome of staphylococcus aureus prosthetic valve infective endocarditis: Analysis in the international collaboration of endocarditis-prospective cohort study

Background. The impact of early valve surgery (EVS) on the outcome of Staphylococcus aureus (SA) prosthetic valve infective endocarditis (PVIE) is unresolved. The objective of this study was to evaluate the association between EVS, performed within the first 60 days of hospitalization, and outcome of SA PVIE within the International Collaboration on Endocarditis-Prospective Cohort Study. Methods. Participants were enrolled between June 2000 and December 2006. Cox proportional hazards modeling that included surgery as a time-dependent covariate and propensity adjustment for likelihood to receive cardiac surgery was used to evaluate the impact of EVS and 1-year all-cause mortality on patients with definite left-sided S. aureus PVIE and no history of injection drug use. Results. EVS was performed in 74 of the 168 (44.3%) patients. One-year mortality was significantly higher among patients with S. aureus PVIE than in patients with non-S. aureus PVIE (48.2% vs 32.9%; P = .003). Staphylococcus aureus PVIE patients who underwent EVS had a significantly lower 1-year mortality rate (33.8% vs 59.1%; P = .001). In multivariate, propensity-adjusted models, EVS was not associated with 1-year mortality (risk ratio, 0.67 [95% confidence interval, .39-1.15]; P = .15). Conclusions. In this prospective, multinational cohort of patients with S. aureus PVIE, EVS was not associated with reduced 1-year mortality. The decision to pursue EVS should be individualized for each patient, based upon infection-specific characteristics rather than solely upon the microbiology of the infection causing PVIE

HACEK infective endocarditis: characteristics and outcomes from a large, multi-national cohort.

The HACEK organisms (Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species) are rare causes of infective endocarditis (IE). The objective of this study is to describe the clinical characteristics and outcomes of patients with HACEK endocarditis (HE) in a large multi-national cohort. Patients hospitalized with definite or possible infective endocarditis by the International Collaboration on Endocarditis Prospective Cohort Study in 64 hospitals from 28 countries were included and characteristics of HE patients compared with IE due to other pathogens. Of 5591 patients enrolled, 77 (1.4%) had HE. HE was associated with a younger age (47 vs. 61 years; p<0.001), a higher prevalence of immunologic/vascular manifestations (32% vs. 20%; p<0.008) and stroke (25% vs. 17% p = 0.05) but a lower prevalence of congestive heart failure (15% vs. 30%; p = 0.004), death in-hospital (4% vs. 18%; p = 0.001) or after 1 year follow-up (6% vs. 20%; p = 0.01) than IE due to other pathogens (n = 5514). On multivariable analysis, stroke was associated with mitral valve vegetations (OR 3.60; CI 1.34-9.65; p<0.01) and younger age (OR 0.62; CI 0.49-0.90; p<0.01). The overall outcome of HE was excellent with the in-hospital mortality (4%) significantly better than for non-HE (18%; p<0.001). Prosthetic valve endocarditis was more common in HE (35%) than non-HE (24%). The outcome of prosthetic valve and native valve HE was excellent whether treated medically or with surgery. Current treatment is very successful for the management of both native valve prosthetic valve HE but further studies are needed to determine why HE has a predilection for younger people and to cause stroke. The small number of patients and observational design limit inferences on treatment strategies. Self selection of study sites limits epidemiological inferences