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P88 PROMPT SYSTEM EXTRACTION DECREASES MORTALITY IN PATIENTS WITH CARDIOVASCULAR IMPLANTABLE ELECTROPHYSIOLOGIC DEVICE INFECTION
Abstracts from 12th ISCVID / International Journal of Antimicrobial Agents 41S1 (2013) S1–S34
Defervescence was achieved at day 8. She was discharged 2 weeks later on oral linezolid and died 13 days later due to septic shock. Literature review: We found 26 cases of TAVI IE including ours. Mean age was 80.7 years (SD 7.4), 56% were males, mean logistic Euroscore at TAVI indication yielded 28.6% estimated mortality (IQR 23.4–40.3), 42.3% had chronic renal failure, 7.7% on hemodialysis, 46.2% had ischemic heart disease, 31% had chronic lung disease and 42.3% were immunosupressed (concomitant cancer, steroid therapy or transplant). TAVI approach was femoral in 65% and transapical in 35%. Twenty-three percent had a pacemaker. Prophylaxis for TAVI was reported in 35%. Twenty-one percent were late PVE, median time from TAVI to IE was 180 days (IQR 65– 365) and 81% accomplished definitive diagnosis according to Duke modified criteria. Median follow-up was 47.5 days (IQR 29–317.5). 34.6% of cases were nosocomially acquired. HF occurred in 42.3% and embolic events in 19.2%. Most common agent was Enterococcus spp. (39%), followed by coagulase-negative staphylococci (19.2%). Median follow-up was 47.5 days (IQR 29–317.5). Mortality during followup was 32%. Twenty-seven percent received surgical treatment, with 14.3% mortality in this group. Conclusions: IE on TAVI is not anecdotal. Its clinical picture resembles early PVE, but it is caused by different microorganisms, predominating enterococci. Around a third of patients are operated, which points to an inaccurate initial indication for TAVI. However, this issue merits further investigation. P88 PROMPT SYSTEM EXTRACTION DECREASES MORTALITY IN PATIENTS WITH CARDIOVASCULAR IMPLANTABLE ELECTROPHYSIOLOGIC DEVICE INFECTION K.Y. Le1 *, D.Z. Uslan2 , L.M. Baddour3 , M.R. Sohail3 , J.M. Prutkin4 , J.E. Peacock Jr.5 , S.B. Danik6 , H.R. Vikram7 , J.M. Miro´ 8 , E. Blank9 , C.K. Naber10 , R.G. Carrillo11 , C.-H. Tseng12 , A.J. Greenspon13 , for the Multicenter Electrophysiologic Device Infection Cohort (MEDIC). 1 Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA, 2Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA, 3Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA, 4Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA, 5 Division of Infectious Diseases, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA, 6Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 7Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA, 8Infectious Diseases Service, Hospital Cl´ınic-IDIBAPS, University of Barcelona, Barcelona, Spain, 9 A ¨ rztin im Studienzentrum Kardiologie, 10Klinik f¨ ur Kardiologie und Angiologie, Elisabeth-Krankenhaus, Essen, Germany, 11Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA, 12Department of Biostatistics, David Geffen School of Medicine, University of California, Los Angeles, California, USA, 13Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA E-mail address: [email protected] Background: Different management strategies of cardiovascular implantable electronic device (CIED) infections may impact patient outcomes. To date, limited prospective data have been evaluated to further characterize this influence on outcomes. Methods: Data from the Multicenter Electrophysiologic Device Infection Cohort (MEDIC), a multinational cohort study of CIED infections, were utilized to evaluate the effects of host comorbidities, device characteristics, and management strategies, on patient outcomes. Results: Of 434 patients who presented with CIED infections, 33 (7.6%) died during the index hospitalization. Mortality was 13.5% for 413 (95.1%) patients for whom follow-up data at 6 months were available. Increased risk of death was observed among patients who had more comorbid conditions, presented with emboli or leukocytosis, or had CIED-related endovascular infections. In multivariate analysis that adjusted for host- and device-related factors and clinical presentation, antimicrobial therapy involving beta-lactams (OR 0.32 [0.13, 0.80]) or vancomycin (OR 0.35 [0.15, 0.85]) when compared to other antimicrobials, was associated with lower mortality at
S33
6 months. Major device removal complications were observed in 6.3% of patients and were associated with increased mortality during the hospitalization and at 6-month follow-up (ORs 10.62 [1.83, 61.60] and 6.09 [1.66, 22.40]). Despite these risks, mortality was three-fold lower during index hospitalization among patients who underwent device removal at initial presentation (OR 0.30 [0.09, 0.96]) as compared to those who had delayed or no device removal. Conclusions: Outcomes in patients with CIED infections are influenced by specific underlying host factors, CIED characteristics, clinical presentation, and approach to therapy. Despite the increased mortality risk associated with complicated device removal, this risk is uncommon and overall outcomes are improved with complete and timely device removal. P89 HEART TRANSPLANTATION FOR COMPLICATED INFECTIVE ENDOCARDITIS M. Aymami1 , C. Chabanne1 , S. Rouze1 , H. Corbineau1 , J.-P. Verhoye1 , C. Blery-Court2 , A. Leguerrier1 , E. Flecher1 *. 1 Chirurgie cardiothoracique, CHU Pontchaillou, Rennes, France, 2 Anesth´esie-r´eanimation Cardiaque, CHU Pontchaillou, Rennes, France E-mail address: erwan.fl[email protected] Introduction: Infective endocarditis is currently medically or surgically treated. Heart transplantation has been exceptionally proposed in isolated case reports. Herein we describe 4 cases of severe endocarditis in which conventional valve replacement was not effective enough to cure the patients. Case descriptions: A 24-year-old man underwent urgent aortic valve replacement for a Staphylococcus aureus endocarditis which recurred 3 weeks later, requiring iterative surgery and temporary mechanical circulatory support. Because of absence of myocardial recovery and after sterilisation of lesions, the patient was registered on the high emergency list for heart transplantation, which was performed 6 weeks after his first operation. A 54-year-old man underwent urgent aortic valve replacement for a Streptococcus pneumoniae endocarditis. After 2 reoperations for infectious recurrences with severe damage to the basis of the heart, the only solution was high emergency heart transplantation 2 months after the primary surgery. A 53-year-old man with a Streptococcus agalactiae aortic valve endocarditis underwent 2 valve replacements before undergoing heart transplantation for acute heart failure one month after his first operation. A 35-year-old man was operated 3 times for a complicated multivalvular Streptococcus pneumoniae endocarditis, and underwent heart transplantation 5 months after initial surgery for end-stage congestive cardiac failure. Results: Early postoperative course was uneventful in all cases after heart transplantation. Post transplantation hospital length of stay was respectively 47 days, 34 days, 30 days, 68 days. Survival is respectively 6 years, 2 years, 6 months, 5 months. Conclusion: High emergency heart transplantation can be indicated in rare and specific cases of endocarditis after failure of valve surgery. In this series we confirm the high destructive potential of Staphylococcus aureus and Streptococcus pneumoniae, needing complete infected tissue eradication. P90 THE ROLE OF SURGERY IN INFECITVE ENDOCARDITIS – SIGNIFICANT IMPACT ON PROGNOSIS OF STAPHYLOCOCCAL ENDOCARDITIS T. Lejko Zupanc *, M. Logar, A.P. Peˇcnik. Department of Infectious Diseases Ljubljana, University Medical Centre Ljubljana, Ljubljana, Slovenia E-mail address: [email protected] Objectives: In recent years surgical treatment of infective endocarditis has become a mainstay in treatment of infective endocarditis. The objective of our study was to evaluate the frequency of surgery and the impact of surgery on the outcome of infective endocarditis in our population of patients.
Defervescence was achieved at day 8. She was discharged 2 weeks later on oral linezolid and died 13 days later due to septic shock. Literature review: We found 26 cases of TAVI IE including ours. Mean age was 80.7 years (SD 7.4), 56% were males, mean logistic Euroscore at TAVI indication yielded 28.6% estimated mortality (IQR 23.4–40.3), 42.3% had chronic renal failure, 7.7% on hemodialysis, 46.2% had ischemic heart disease, 31% had chronic lung disease and 42.3% were immunosupressed (concomitant cancer, steroid therapy or transplant). TAVI approach was femoral in 65% and transapical in 35%. Twenty-three percent had a pacemaker. Prophylaxis for TAVI was reported in 35%. Twenty-one percent were late PVE, median time from TAVI to IE was 180 days (IQR 65– 365) and 81% accomplished definitive diagnosis according to Duke modified criteria. Median follow-up was 47.5 days (IQR 29–317.5). 34.6% of cases were nosocomially acquired. HF occurred in 42.3% and embolic events in 19.2%. Most common agent was Enterococcus spp. (39%), followed by coagulase-negative staphylococci (19.2%). Median follow-up was 47.5 days (IQR 29–317.5). Mortality during followup was 32%. Twenty-seven percent received surgical treatment, with 14.3% mortality in this group. Conclusions: IE on TAVI is not anecdotal. Its clinical picture resembles early PVE, but it is caused by different microorganisms, predominating enterococci. Around a third of patients are operated, which points to an inaccurate initial indication for TAVI. However, this issue merits further investigation. P88 PROMPT SYSTEM EXTRACTION DECREASES MORTALITY IN PATIENTS WITH CARDIOVASCULAR IMPLANTABLE ELECTROPHYSIOLOGIC DEVICE INFECTION K.Y. Le1 *, D.Z. Uslan2 , L.M. Baddour3 , M.R. Sohail3 , J.M. Prutkin4 , J.E. Peacock Jr.5 , S.B. Danik6 , H.R. Vikram7 , J.M. Miro´ 8 , E. Blank9 , C.K. Naber10 , R.G. Carrillo11 , C.-H. Tseng12 , A.J. Greenspon13 , for the Multicenter Electrophysiologic Device Infection Cohort (MEDIC). 1 Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA, 2Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA, 3Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA, 4Division of Cardiology, University of Washington Medical Center, Seattle, Washington, USA, 5 Division of Infectious Diseases, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA, 6Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 7Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA, 8Infectious Diseases Service, Hospital Cl´ınic-IDIBAPS, University of Barcelona, Barcelona, Spain, 9 A ¨ rztin im Studienzentrum Kardiologie, 10Klinik f¨ ur Kardiologie und Angiologie, Elisabeth-Krankenhaus, Essen, Germany, 11Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA, 12Department of Biostatistics, David Geffen School of Medicine, University of California, Los Angeles, California, USA, 13Division of Cardiology, Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA E-mail address: [email protected] Background: Different management strategies of cardiovascular implantable electronic device (CIED) infections may impact patient outcomes. To date, limited prospective data have been evaluated to further characterize this influence on outcomes. Methods: Data from the Multicenter Electrophysiologic Device Infection Cohort (MEDIC), a multinational cohort study of CIED infections, were utilized to evaluate the effects of host comorbidities, device characteristics, and management strategies, on patient outcomes. Results: Of 434 patients who presented with CIED infections, 33 (7.6%) died during the index hospitalization. Mortality was 13.5% for 413 (95.1%) patients for whom follow-up data at 6 months were available. Increased risk of death was observed among patients who had more comorbid conditions, presented with emboli or leukocytosis, or had CIED-related endovascular infections. In multivariate analysis that adjusted for host- and device-related factors and clinical presentation, antimicrobial therapy involving beta-lactams (OR 0.32 [0.13, 0.80]) or vancomycin (OR 0.35 [0.15, 0.85]) when compared to other antimicrobials, was associated with lower mortality at
S33
6 months. Major device removal complications were observed in 6.3% of patients and were associated with increased mortality during the hospitalization and at 6-month follow-up (ORs 10.62 [1.83, 61.60] and 6.09 [1.66, 22.40]). Despite these risks, mortality was three-fold lower during index hospitalization among patients who underwent device removal at initial presentation (OR 0.30 [0.09, 0.96]) as compared to those who had delayed or no device removal. Conclusions: Outcomes in patients with CIED infections are influenced by specific underlying host factors, CIED characteristics, clinical presentation, and approach to therapy. Despite the increased mortality risk associated with complicated device removal, this risk is uncommon and overall outcomes are improved with complete and timely device removal. P89 HEART TRANSPLANTATION FOR COMPLICATED INFECTIVE ENDOCARDITIS M. Aymami1 , C. Chabanne1 , S. Rouze1 , H. Corbineau1 , J.-P. Verhoye1 , C. Blery-Court2 , A. Leguerrier1 , E. Flecher1 *. 1 Chirurgie cardiothoracique, CHU Pontchaillou, Rennes, France, 2 Anesth´esie-r´eanimation Cardiaque, CHU Pontchaillou, Rennes, France E-mail address: erwan.fl[email protected] Introduction: Infective endocarditis is currently medically or surgically treated. Heart transplantation has been exceptionally proposed in isolated case reports. Herein we describe 4 cases of severe endocarditis in which conventional valve replacement was not effective enough to cure the patients. Case descriptions: A 24-year-old man underwent urgent aortic valve replacement for a Staphylococcus aureus endocarditis which recurred 3 weeks later, requiring iterative surgery and temporary mechanical circulatory support. Because of absence of myocardial recovery and after sterilisation of lesions, the patient was registered on the high emergency list for heart transplantation, which was performed 6 weeks after his first operation. A 54-year-old man underwent urgent aortic valve replacement for a Streptococcus pneumoniae endocarditis. After 2 reoperations for infectious recurrences with severe damage to the basis of the heart, the only solution was high emergency heart transplantation 2 months after the primary surgery. A 53-year-old man with a Streptococcus agalactiae aortic valve endocarditis underwent 2 valve replacements before undergoing heart transplantation for acute heart failure one month after his first operation. A 35-year-old man was operated 3 times for a complicated multivalvular Streptococcus pneumoniae endocarditis, and underwent heart transplantation 5 months after initial surgery for end-stage congestive cardiac failure. Results: Early postoperative course was uneventful in all cases after heart transplantation. Post transplantation hospital length of stay was respectively 47 days, 34 days, 30 days, 68 days. Survival is respectively 6 years, 2 years, 6 months, 5 months. Conclusion: High emergency heart transplantation can be indicated in rare and specific cases of endocarditis after failure of valve surgery. In this series we confirm the high destructive potential of Staphylococcus aureus and Streptococcus pneumoniae, needing complete infected tissue eradication. P90 THE ROLE OF SURGERY IN INFECITVE ENDOCARDITIS – SIGNIFICANT IMPACT ON PROGNOSIS OF STAPHYLOCOCCAL ENDOCARDITIS T. Lejko Zupanc *, M. Logar, A.P. Peˇcnik. Department of Infectious Diseases Ljubljana, University Medical Centre Ljubljana, Ljubljana, Slovenia E-mail address: [email protected] Objectives: In recent years surgical treatment of infective endocarditis has become a mainstay in treatment of infective endocarditis. The objective of our study was to evaluate the frequency of surgery and the impact of surgery on the outcome of infective endocarditis in our population of patients.