C. Falces

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.

Emerging risk factors and the dose-response relationship between physical activity and lone atrial fibrillation: a prospective case-control study.

Abstract Aims The role of high-intensity exercise and other emerging risk factors in lone atrial fibrillation (Ln-AF) epidemiology is still under debate. The aim of this study was to analyse the contribution of each of the emerging risk factors and the impact of physical activity dose in patients with Ln-AF. Methods and results Patients with Ln-AF and age- and sex-matched healthy controls were included in a 2:1 prospective case–control study. We obtained clinical and anthropometric data transthoracic echocardiography, lifetime physical activity questionnaire, 24-h ambulatory blood pressure monitoring, Berlin questionnaire score, and, in patients at high risk for obstructive sleep apnoea (OSA) syndrome, a polysomnography. A total of 115 cases and 57 controls were enrolled. Conditional logistic regression analysis associated height [odds ratio (OR) 1.06 [1.01–1.11]], waist circumference (OR 1.06 [1.02–1.11]), OSA (OR 5.04 [1.44–17.45]), and 2000 or more hours of cumulative high-intensity endurance training to a higher AF risk. Our data indicated a U-shaped association between the extent of high-intensity training and AF risk. The risk of AF increased with an accumulated lifetime endurance sport activity ≥2000 h compared with sedentary individuals (OR 3.88 [1.55–9.73]). Nevertheless, a history of <2000 h of high-intensity training protected against AF when compared with sedentary individuals (OR 0.38 [0.12–0.98]). Conclusion A history of ≥2000 h of vigorous endurance training, tall stature, abdominal obesity, and OSA are frequently encountered as risk factors in patients with Ln-AF. Fewer than 2000 total hours of high-intensity endurance training associates with reduced Ln-AF risk.

Left atrial dysfunction relates to symptom onset in patients with heart failure and preserved left ventricular ejection fraction

AIMS Pathophysiology of heart failure (HF) with preserved ejection fraction (HFPEF) remains unclear. Left atrial (LA) function has been related to HF symptoms. Our purpose is to analyse LA function in outpatients with new onset symptoms of HF. METHODS AND RESULTS An observational study was performed including 138 consecutive outpatients with suspected HF referred to a one-stop clinic. Final diagnosis [HF with reduced EF (HFREF), HFPEF, or non-HF] was established according to current recommendations. Echocardiography was performed in all patients. LA function was analysed using strain derived from speckle tracking in sinus rhythm patients (n = 83). Results were analysed with ANOVA and Bonferroni statistical tests. Receiver operating characteristic (ROC) curves were constructed to investigate the predictive ability of LA parameters for the final diagnosis of HF. Patients were 75 ± 9 years and 63% women. Final diagnosis was 23.2% HFREF, 45.7% HFPEF, and 31.2% non-HF. Left ventricular strain rate showed no differences between non-HF and HFPEF groups, but both groups showed differences with the HFREF group. LA strain rate (A- and S-waves) was significantly reduced in both HF groups (without differences among them) when compared with the non-HF group. LA strain rate and indexed volume showed significant accuracy for HF diagnosis in ROC curves. CONCLUSIONS In outpatients with new-onset symptoms of HF, LA dysfunction was observed. It might be the initial mechanism in the development of symptoms in HFPEF patients. These findings support the relationship of LA dysfunction with HFPEF, suggesting that the analysis of LA function may be useful in sinus rhythm patients with new-onset dyspnoea.

The Changing Epidemiology of Infective Endocarditis in the Twenty-First Century

Purpose of the ReviewInfective endocarditis (IE) is a relatively infrequent infectious disease. It does, however, causes serious morbidity, and its mortality rate has remained unchanged at approximately 25%. Changes in IE risk factors have deeply impacted its epidemiology during recent decades but literature from low-income countries is very scarce. Moreover, prophylaxis guidelines have recently changed and the impact on IE incidence is still unknown.Recent FindingsIn high-income countries, the proportion of IE related to prior rheumatic disease has decreased significantly and has been replaced proportionally by cases related to degenerative valvulopathies, prosthetic valves, and cardiovascular implantable electronic devices. Nosocomial and non-nosocomial-acquired cases have risen, as has the proportion caused by staphylococci, and the median age of patients. In low-income countries, in contrast, rheumatic disease remains the main risk factor, and streptococci the most frequent causative agents. Studies performed to evaluate impact of guidelines changes’ have shown contradictory results.SummaryThe increased complexity of cases in high-income countries has led to the creation of IE teams, involving several specialties. New imaging and microbiological techniques may increase sensitivity for diagnosis and detection of IE cases. In low-income countries, IE remained related to classic risk factors. The consequences of prophylaxis guidelines changes are still undetermined.

Prognosis of new-onset heart failure outpatients and collagen biomarkers

Prognosis of heart failure patients has been defined in hospital‐based or retrospective studies. This study aimed to characterize prognosis of outpatients with new‐onset preserved or reduced ejection fraction heart failure; to explore the role of collagen turnover biomarkers (MMP2, MMP9, TIMP1) in predicting prognosis; and to analyse their relationship with echocardiographic parameters and final diagnosis.

Epidemiology, Clinical Features, and Outcome of Infective Endocarditis due to Abiotrophia Species and Granulicatella Species: Report of 76 Cases, 2000–2015

Background Infective endocarditis (IE) caused by Abiotrophia (ABI) and Granulicatella (GRA) species is poorly studied. This work aims to describe and compare the main features of ABI and GRA IE. Methods We performed a retrospective study of 12 IE institutional cases of GRA or ABI and of 64 cases published in the literature (overall, 38 ABI and 38 GRA IE cases). Results ABI/GRA IE represented 1.51% of IE cases in our institution between 2000 and 2015, compared to 0.88% of HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella)-related IE and 16.62% of Viridans group streptococci (VGS) IE. Institutional ABI/GRA IE case characteristics were comparable to that of VGS, but periannular complications were more frequent (P = .008). Congenital heart disease was reported in 4 (10.5%) ABI and in 11 (28.9%) GRA cases (P = .04). Mitral valve was more frequently involved in ABI than in GRA (P < .001). Patient sex, prosthetic IE, aortic involvement, penicillin susceptibility, and surgical treatment were comparable between the genera. New-onset heart failure was the most frequent complication without genera differences (P = .21). Five (13.2%) ABI patients and 2 (5.3%) GRA patients died (P = .23). Factors associated with higher mortality were age (P = .02) and new-onset heart failure (P = .02). The genus (GRA vs ABI) was not associated with higher mortality (P = .23). Conclusions GRA/ABI IE was more prevalent than HACEK IE and approximately one-tenth as prevalent as VGS; periannular complications were more frequent. GRA and ABI genera IE presented similar clinical features and outcomes. Overall mortality was low, and related to age and development of heart failure.

Interatrial Dyssynchrony May Contribute to Heart Failure Symptoms in Patients with Preserved Ejection Fraction.

Heart failure (HF) with preserved ejection fraction (HFPEF) is the most prevalent type of HF in nonhospitalized patients, but its pathophysiology remains poorly understood. The aim of our study was to assess the existence of interatrial dyssynchrony (IAD), a potentially treatable condition, in the development of HF symptoms.

Profilaxis antibiótica de la endocarditis infecciosa: a quién y cuándo se debe recomendar

La Asociación Americana del Corazón (American Heart Association, AHA) ha publicado recientemente la actualización de sus recomendaciones en la prevención de la endocarditis infecciosa (EI). Los autores hacen una revisión de los criterios para establecer las pautas de profilaxis y valoran su utilidad con la evidencia científica de los pocos estudios llevados a cabo en estos años. Fruto de estas consideraciones son unas nuevas recomendaciones que limitan de forma muy notable los pacientes candidatos a recibir profilaxis y los procedimientos en que se tiene que aplicar. La EI es una enfermedad poco frecuente, pero que conlleva una elevada morbilidad y mortalidad. A pesar de los progresos médicos y quirúrgicos que se han hecho en su diagnóstico y tratamiento, la EI sigue siendo una enfermedad grave con una alta tasa de mortalidad en la fase inicial. La recomendación de administrar antibióticos de forma previa a un procedimiento médico que pueda provocar una bacteriemia transitoria en pacientes con riesgo de contraer EI ha sido ampliamente difundida durante décadas. Tradicionalmente, los comités de expertos se han basado en una secuencia lógica de premisas: la EI es una enfermedad poco frecuente, pero que conlleva una elevada morbimortalidad; se tiene constancia de que determinadas cardiopatías predisponen a la EI; determinados procedimientos dan lugar a bacteriemias transitorias que pueden causar una EI; en modelos experimentales en animales se ha demostrado la eficacia de la profilaxis antibiótica en prevenir la EI; la profilaxis en humanos es efectiva en la prevención de la EI asociada a procedimientos dentales, del tracto gastrointestinal o genitourinario, todo ello en pacientes con determinadas cardiopatías. El comité de expertos de la AHA en sus últimas recomendaciones confirma la validez de los primeros cuatro fundamentos pero pone en duda el último: la validez de la profilaxis antibiótica en el ser humano. Los estudios con modelos experimentales en animales han confirmado que la profilaxis antibiótica es efectiva en la prevención de la EI, pero ningún estudio prospectivo ha probado su eficacia en un ensayo clínico y los pocos estudios de casos y controles llevados a cabo no son concluyentes. Además, estudios recientes muestran los cambios etiológicos de la EI en las últimas décadas, pasando de un predominio tradicional de las EI causadas por estreptococos del grupo viridans a microorganismos no orales como Staphylococcus aureus lo que resta aún más consistencia a la profilaxis antibiótica de la EI tal y como se ha concebido hasta ahora. Las recomendaciones de los Comités de Expertos franceses y británicos en los últimos dos años se hacen eco de la falta de evidencias clínicas suficientes que justifiquen la práctica de la profilaxis antibiótica. Por ello recomiendan el uso de profilaxis sólo en pacientes de alto riesgo, siendo opcional la profilaxis antibiótica en los pacientes catalogados de bajo riesgo. El Comité Europeo es el más conservador y mantiene en sus recomendaciones del año 2004 un mayor número de procedimientos y pacientes candidatos a recibir la profilaxis. Las últimas recomendaciones de la AHA del año 2007 son más restrictivas que sus predecesoras. En ellas se recoge la opinión de expertos que han sugerido que las manipulaciones dentales o de la mucosa oral no son una causa importante de EI o que su efectividad no se compensa con los posibles costes, por lo que la profilaxis antibiótica en la mayoría de los casos no estaría justificada. Estas modificaciones y opiniones han generado un intenso debate en el entorno médico. En cambio, sí se ha demostrado que actividades cotidianas como cepillarse los dientes o masticar dan lugar a pequeñas bacteriemias transitorias que tendrían un efecto acumulativo muy superior al de un procedimiento dental aislado. Con este conocimiento, cobra mayor importancia la prevención con la educación del paciente en sus hábitos y el mantener una higiene dental correcta, recomendando revisiones de la boca por sistema, al menos dos veces al año. Debido a los cambios observados en la epidemiología de la EI, el Comité de Expertos francés recomienda evitar en los pacientes de riesgo cualquier procedimiento que ocasione heridas de la piel o mucosas como el “piercing”, tatuajes o la acupuntura a diferencia de las últimas recomendaciones de la AHA. También ponen especial atención en los catéteres para infusión que recomienda usar sólo cuando sea estrictamente obligatorio y preferiblemente catéteres periféricos a catéteres centrales y recomiendan el cambio sistemático de estos catéteres cada tres o cuatro días, hecho que no se menciona en las recomendaciones de la AHA, con el fin de reducir el riesgo de bacteriemia estafilocócica asociada a los catéteres, que tiene una elevada morbilidad.

Correction: Outcome of Enterococcus faecalis infective endocarditis according to the length of antibiotic therapy: Preliminary data from a cohort of 78 patients

[This corrects the article DOI: 10.1371/journal.pone.0192387.].

HACEK infective endocarditis: Epidemiology, clinical features, and outcome: A case–control study

OBJECTIVES The study aimed to describe the epidemiological, microbiological, and clinical features of a population sample of 17 patients with HACEK infective endocarditis (HACEK-IE) and to compare them with matched control patients with IE caused by viridans group streptococci (VGS-IE). METHODS Cases of definite (n=14, 82.2%) and possible (n=3, 17.6%) HACEK-IE included in the Infective Endocarditis Hospital Clinic of Barcelona (IE-HCB) database between 1979 and 2016 were identified and described. Furthermore, a retrospective case-control analysis was performed, matching each case to three control subjects with VGS-IE registered in the same database during the same time period. RESULTS Seventeen out of 1209 IE cases (1.3%, 95% confidence interval 0.69-1.91%) were due to HACEK group organisms. The most frequently isolated HACEK species were Aggregatibacter spp (n=11, 64.7%). Intracardiac vegetations were present in 70.6% of cases. Left heart failure (LHF) was present in 29.4% of cases. Ten patients (58.8%) required in-hospital surgery and none died during hospitalization. In the case-control analysis, there was a trend towards larger vegetations in the HACEK-IE group (median (interquartile range) size 11.5 (10.0-20.0) mm vs. 9.0 (7.0-13.0) mm; p=0.068). Clinical manifestations, echocardiographic findings, LHF rate, systemic emboli, and other complications were all comparable (p>0.05). In-hospital surgery and mortality were similar in the two groups. One-year mortality was lower for HACEK-IE (1/17 vs. to 6/48; p=0.006). CONCLUSIONS HACEK-IE represented 1.3% of all IE cases. Clinical features and outcomes were comparable to those of the VGS-IE control group. Despite the trend towards a larger vegetation size, the embolic event rate was not higher and the 1-year mortality was significantly lower for HACEK-IE.