C.A. Mestres

Staphylococcus lugdunensis infective endocarditis: description of 10 cases and analysis of native valve, prosthetic valve, and pacemaker lead endocarditis clinical profiles

Objective: To evaluate the incidence and the clinical and echocardiographic features of infective endocarditis (IE) caused by Staphylococcus lugdunensis and to identify the prognostic factors of surgery and mortality in this disease. Design: Prospective cohort study. Setting: Study at two centres (a tertiary care centre and a community hospital). Patients: 10 patients with IE caused by S lugdunensis in 912 consecutive patients with IE between 1990 and 2003. Methods: Prospective study of consecutive patients carried out by the multidisciplinary team for diagnosis and treatment of IE from the study institutions. English, French, and Spanish literature was searched by computer under the terms “endocarditis” and “Staphylococcus lugdunensis” published between 1989 and December 2003. Main outcome measures: Patient characteristics, echocardiographic findings, required surgery, and prognostic factors of mortality in left sided cases of IE. Results: 10 cases of IE caused by S lugdunensis were identified at our institutions, representing 0.8% (four of 467), 1.5% (two of 135), and 7.8% (four of 51) of cases of native valve, prosthetic valve, and pacemaker lead endocarditis in the non-drug misusers. Native valve IE was present in four patients (two aortic, one mitral, and one pulmonary), prosthetic valve aortic IE in two patients, and pacemaker lead IE in the other four patients. All patients with left sided IE had serious complications (heart failure, periannular abscess formation, or shock) requiring surgery in 60% (three of five patients) of cases with an overall mortality rate of 80% (four of five patients). All patients with pacemaker IE underwent combined medical treatment and surgery, and mortality was 25% (one patient). In total 59 cases of IE caused by S lugdunensis were identified in a review of the literature. The combined analysis of these 69 cases showed that native valve IE (53 patients, 77%) is characterised by mitral valve involvement and frequent complications such as heart failure, abscess formation, and embolism. Surgery was needed in 51% of cases and mortality was 42%. Prosthetic valve endocarditis (nine of 60, 13%) predominated in the aortic position and was associated with abscess formation, required surgery, and high mortality (78%). Pacemaker lead IE (seven of 69, 10%) is associated with a better prognosis when antibiotic treatment is combined with surgery. Conclusions:S lugdunensis IE is an uncommon cause of IE, involving mainly native left sided valves, and it is characterised by an aggressive clinical course. Mortality in left sided native valve IE is high but the prognosis has improved in recent years. Surgery has improved survival in left sided IE and, therefore, early surgery should always be considered. Prosthetic valve S lugdunensis IE carries an ominous prognosis.

Daptomycin Is Effective for Treatment of Experimental Endocarditis Due to Methicillin-Resistant and Glycopeptide-Intermediate Staphylococcus epidermidis

ABSTRACT This study evaluated the daptomycin activity against two methicillin-resistant Staphylococcus epidermidis (MRSE) clinical isolates with different vancomycin susceptibilities: MRSE-375, with a vancomycin MIC of 2 μg/ml, and NRS6, a glycopeptide-intermediate S. epidermidis (GISE) strain with a vancomycin MIC of 8 μg/ml. The in vivo activity of daptomycin at two different doses (standard dose [SD-daptomycin], 6 mg/kg of body weight/day intravenously [i.v.]; high dose [HD-daptomycin], 10 mg/kg/day i.v.) was evaluated in a rabbit model of infective endocarditis and compared with that of a standard dose of vancomycin (SD-vancomycin; 1 g i.v. every 12 h) for 2 days. For the MRSE-375 strain, high-dose vancomycin (HD-vancomycin; 1 g i.v. every 6 h) was also studied. For MRSE-375, SD- and HD-daptomycin therapy sterilized significantly more vegetations than SD-vancomycin therapy (9/15 [60%] and 11/15 [73%] vegetations, respectively, versus 3/16 [19%] vegetations; P = 0.02 and P = 0.002, respectively). HD-daptomycin sterilized more vegetations than HD-vancomycin (11/15 [73%] versus 5/15 [33%] vegetations; P = 0.03) and was more effective than SD- and HD-vancomycin in reducing the density of bacteria in valve vegetations (0 log10 CFU/g vegetation [interquartile range {IQR}, 0 to 1 log10 CFU/g vegetation] versus 2 log10 CFU/g vegetation [IQR, 2 to 2 log10 CFU/g vegetation] and 2 log10 CFU/g vegetation [IQR, 0 to 2.8 log10 CFU/g vegetation]; P = 0.002 and P = 0.01, respectively). For the NRS6 strain, SD- and HD-daptomycin were significantly more effective than vancomycin in reducing the density of bacteria in valve vegetations (3.7 log10 CFU/g vegetation [IQR, 2 to 6 log10 CFU/g vegetation] versus 7.1 log10 CFU/g vegetation [IQR, 5.2 to 8.5 log10 CFU/g vegetation]; P = 0.02). In all treatment arms, isolates recovered from vegetations remained susceptible to daptomycin and vancomycin and had the same MICs. In conclusion, daptomycin at doses of 6 mg/kg/day or 10 mg/kg/day is more effective than vancomycin for the treatment of experimental endocarditis due to MRSE and GISE.

Addition of Gentamicin or Rifampin Does Not Enhance the Effectiveness of Daptomycin in Treatment of Experimental Endocarditis Due to Methicillin-Resistant Staphylococcus aureus

ABSTRACT This study evaluated the activity of daptomycin combined with either gentamicin or rifampin against three methicillin-resistant Staphylococcus aureus (MRSA) clinical isolates in vitro and one isolate in vivo against a representative strain (MRSA-572). Time-kill experiments showed that daptomycin was bactericidal against these strains at concentrations over the MIC. Daptomycin at sub-MIC concentrations plus gentamicin at 1× and 2× the MIC yielded synergy, while the addition of rifampin at 2 to 4 μg/ml resulted in indifference (two strains) or antagonism (one strain). The in vivo activity of daptomycin (6 mg/kg of body weight once a day) was evaluated ± gentamicin (1 mg/kg intravenously [i.v.] every 8 h [q8h]) or rifampin (300 mg i.v. q8h) in a rabbit model of infective endocarditis by simulating human pharmacokinetics. Daptomycin plus gentamicin (median, 0 [interquartile range, 0 to 2] log10 CFU/g vegetation) was as effective as daptomycin alone (0 [0 to 2] log10 CFU/g vegetation) in reducing the density of bacteria in valve vegetations (P = 0.83), and both were more effective than daptomycin plus rifampin (3 [2 to 3.5] log10 CFU/g vegetation; P < 0.05) for the strain studied. In addition, daptomycin sterilized a ratio of vegetations that was similar to that of daptomycin plus gentamicin (10/15 [67%] versus 9/15 [60%]; P = 0.7), and both regimens did so more than daptomycin plus rifampin (3/15 [20%]; P = 0.01 and P = 0.02, respectively). No statistical difference was noted between daptomycin plus gentamicin and daptomycin alone for MRSA treatment. In the combination arm, all isolates from vegetations remained susceptible to daptomycin, gentamicin, and rifampin. Sixty-one percent of the isolates (8/13) acquired resistance to rifampin during monotherapy. In the daptomycin arm, resistance was detected in only one case, in which the daptomycin MIC rose to 2 μg/ml among the recovered bacteria. In conclusion, the addition of gentamicin or rifampin does not enhance the effectiveness of daptomycin in the treatment of experimental endocarditis due to MRSA.

Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular

BACKGROUND To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

279. El derrame pericárdico postoperatorio en cirugía cardíaca: Incidencia e impacto en los resultados quirúrgicos

Objetivos El derrame pericardico (DP) es una complicacion (40–65%) que puede determinar taponamiento diferido letal. Determinamos la incidencia de DP grave en el postoperatorio de cirugia cardiaca. Material y metodos Estudio prospectivo de cohorte de pacientes consecutivos no seleccionados con intervenciones mayores de cirugia cardiaca. Se practico estudio ecocardiografico prealta. Se diagnostico DP por criterios de Horowitz en modo M. Para la ecocardiografia-2D se consideraron diagnosticos de taponamiento cardiaco: colapso diastolico precoz del ventriculo derecho, compresion de cavidades cardiacas, pletora de vena cava inferior y variaciones superiores al 30% del flujo mitral. Con independencia de los estudios intraoperatorios o en cuidados intensivos, se programo estudio prealta a partir del septimo dia postoperatorio. Las ecocardiografias se practicaron en el laboratorio de ecocardiografia. Si la condicion del paciente no lo permitio, el estudio se realizo en las unidades de hospitalizacion en los casos urgentes. Se usaron los ecografos Vivid i/Vivid 7 (General Electric, Fairfield, CT). Todos los estudios fueron supervisados por los ecocardiografistas expertos del servicio de cardiologia. Resultados De noviembre de 2009 – noviembre de 2011 se intervinieron 1.186 pacientes; 125 fueron trasladados precozmente a su hospital; 88 fallecieron sin estudio. De 973 pacientes, 53 (5,4%) presentaron DP grave o taponamiento por criterios clinicos/ecocardiograficos; 31/53 (58%) estaban asintomaticos. En 22/53 (42%) hubo sospecha clinica. Fueron reintervenidos 21 (40%). En 16 (30%) se administraron antiinflamatorios no esteroideos (AINE) y corticoides. La mortalidad fue 3,8% (2/53). Conclusion La ecocardiografia es una exploracion inocua que permite el diagnostico rapido de DP potencialmente letal, que tiene un componente medicolegal. Debe realizarse a todo postoperado de cirugia cardiaca.

265. Afectación del bazo en la endocarditis infecciosa: Un enemigo silencioso

Introduccion y objetivos La endocarditis infecciosa predispone al absceso esplenico, de incidencia mal definida y que aumenta la morbimortalidad. No esta estandarizado el momento para esplenectomia cuando se requiere intervencion por endocarditis. Se describe la experiencia con endocarditis y patologia esplenica asociada e indicacion quirurgica valvular y esplenica. Material y metodos Revision retrospectiva de la base de datos prospectiva de endocarditis, definida por criterios modificados de Duke. Analisis de pacientes diagnosticados de infarto/absceso esplenico mediante imagen/estudio post mortem . En los casos de esplenectomia, se practico en la misma intervencion despues del procedimiento valvular. Resultados Entre enero de 1995 – julio de 2011 se recogieron 737 episodios de endocarditis; 62 (8,41%) pacientes presentaron infarto/absceso esplenico con fiebre persistente y dolor abdominal; 6 (8,9%) requirieron esplenectomia; 5 (83%) eran varones. La edad media fue 52 (27–72). EuroSCORE logistico medio fue 37,42% (18,83–60,93%). La endocarditis fue mitral (3), aortica (2) y multivalvular (mitral y tricuspide). Se aislaron Enterococcus spp (2), Staphylococcus aureus (1), estreptococos del grupo viridans (1), Kingella kingae (1) y hemocultivos negativos (1). El absceso esplenico se diagnostico por tomografia (4); en 2 la intervencion fue urgente, sin imagen. Se practico sustitucion valvular. Tres (50%) fallecieron. En los 6 se confirmo absceso esplenico por histopatologia. El seguimiento de los supervivientes a la intervencion con esplenectomia fue de 16, 22 y 36 meses, sin recidiva. Conclusiones Debe sospecharse absceso esplenico en los pacientes con endocarditis, fiebre y dolor abdominal. La esplenectomia y la intervencion valvular pueden realizarse en el mismo acto dependiendo de la condicion del paciente.

104 SURGERY OF INFECTIVE ENDOCARDITIS IN PATIENTS WITH LIVER CIRRHOSIS: A DIFFICULT DECISION-MAKING PROCESS

IE and 1,110 cases of IE due to other pathogens (non-SA NVIE). Twogroup comparisons and adjusted survival analysis were performed. Results: Compared to non-SA NVIE, SA NVIE occurred more frequently in older subjects (p = 0.01). It was less often community-acquired (p < 10 4), more frequently diagnosed within the first month of symptoms onset (p < 10 4) and associated with comorbidities (p < 10 4). SA NVIE was more often complicated with stroke (p = 0.0009) and emboli (p = 0.008). By contrast the frequencies of cardiac failure and intracardiac abscess were the same in the two groups. EVS and 60day in-hospital mortality rate were lower (34.2% vs. 50.1%, p < 10 4) and higher (26.5% vs. 11.9%, p < 10 4), respectively. In multivariate analysis, when compared to non-SA NVIE: (1) the probability of EVS was significantly lower in SA NVIE (HR 0.66, 95 CI 0.54 0.80, p < 0.0001); (2) the probability of in-hospital death was significantly higher (HR 1.68, 95 CI 1.28 2.22, p < 0.0001), which was true both in operated and non-operated patients. Conclusion: This study confirms that SA NVIE is associated with higher rates of comorbidities and mortality. It is also associated with a lower rate of EVS, which is neither explained by a higher frequency of comorbidities/complications that would contraindicate surgery nor by a lower frequency of conditions that would require surgery.

084 TRENDS IN GLYCOPEPTIDE AND DAPTOMYCIN SUSCEPTIBILITIES IN STAPHYLOCOCCUS EPIDERMIDIS ISOLATED FROM INFECTIVE ENDOCARDITIS (IE) OVER TIME (1992 2008)

084 TRENDS IN GLYCOPEPTIDE AND DAPTOMYCIN SUSCEPTIBILITIES IN STAPHYLOCOCCUS EPIDERMIDIS ISOLATED FROM INFECTIVE ENDOCARDITIS (IE) OVER TIME (1992 2008) Y. Armero1 *, C. Garcia de la Maria1, C. Cervera2, A. Moreno2, S. Ninot3, M. Almela1, A. del Rio2, C. Falces4, C. Mestres3, M. Jimenez de Anta1, J. Gatell2, F. Marco1, J. Miro2. 1Hospital Clinic-IDIBAPS, Microbiology, Barcelona, Spain, 2Hospital Clinic-IDIBAPS, Infectious Diseases, Barcelona, Spain, 3Hospital Clinic-IDIBAPS, Cardiac Surgery, Barcelona, Spain, 4Hospital Clinic-IDIBAPS, Cardiology, Barcelona, Spain

The Gore-Tex Surgical Membrane for Temporary Skin Closure after Complicated Cardiac Operations

Between April 1986 and March 1989, 12 patients, 7 male and 5 female with a mean age of 50.0 years underwent temporary skin closure after complicated cardiac operations with the Gore-Tex Surgical Membrane and the indications to delay primary closure of the sternume were myocardial edema, uncontrollable hemorrhage and additional cannulations needed for mechanical circulatory support. Seven patients (58%) finally underwent sternal closure. Five patients survived and left the hospital (42%). No superficial nor deep infection developed in survivors. The analysis of 3 explanted membranes showed no bacterial growth.