- Email: [email protected]
When the Cat's Out of the Bag
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 67, NO. 2, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacc.2015.10.066
EDITORIAL COMMENT
When the Cat’s Out of the Bag Searching for Portals of Entry in Infective Endocarditis* Vivian H. Chu, MD, MHS
I
nfective endocarditis (IE) often poses challenges
Furthermore, the investigators found that one-third
of the diagnostic and/or treatment variety. Take,
of patients had additional POEs that could serve as
for instance, the case of a 24-year-old man with
sources for new IE episodes. This study grapples with
congenital heart disease who is diagnosed with Barto-
the issue of source identification in patients with IE, a
nella henselae IE. Patient: “What’s the next step,
ubiquitous concern that has been sparsely addressed
doc?” Physician: “You will have a peripherally
in published medical research.
inserted central catheter in your arm through which
The identification of POEs and subsequent eradi-
you will receive intravenous antibiotics for 6 weeks.
cation of sources of infection is particularly important
This will be followed by at least 3 to 6 months of
in IE because having IE in the first place puts one at
oral antibiotics, potentially longer. These antibiotics
risk for subsequent IE. In the published research, the
may cause diarrhea. You will need to have your pace-
lifetime risk for a repeat episode of IE ranges from 2%
maker removed and then replaced. If your heart valve
to 30% (2,3). In a large multicenter cohort of patients
falters, you will need to have open heart surgery to
with IE, history of IE was an independent predictor of
replace your heart valve.” And now for the really
repeat IE (4), highlighting the importance of obtain-
bad news: “You have to give away your cat.sorry.”
ing timely source control in patients with IE.
SEE PAGE 151
In this issue of the Journal, Delahaye et al. (1) report the results of a single-center study examining portals of entry (POEs) in IE. In this study, a total of 318 patients hospitalized for IE between 2005 and 2011 were systematically evaluated by a dentist, ear, nose, and throat specialist, urologist (women were evaluated by a gynecologist), and, if indicated on examination, a dermatologist. Brain and body radiological
scans
were
systematically
performed.
A gastrointestinal (GI) evaluation, including colonoscopy and gastroscopy, was performed if the infecting pathogen was a GI microorganism and/or if the patient was $50 years of age or at high risk for colorectal cancer. POEs were identified in 74% of the patients. The largest group of POEs were cutaneous (40%), followed by oral or dental (29%) and GI (23%).
PREVENTION OF INFECTIVE ENDOCARDITIS: CAN WE DO MORE? The discussion surrounding IE prevention has evolved over time and, in the United States and Europe, focuses primarily on the use of antibiotic prophylaxis before dental procedures in high-risk patients (5,6). Patients with histories of IE fall into the high-risk category, making them eligible for antibiotic prophylaxis. Are we done here? According to 1 study, the intensity of bacteremia required to cause IE in an animal model was at least 4 orders of magnitude greater than the intensity of bacteremia after tooth extraction in humans (7). In another study, the cumulative exposure to bacteremia after tooth brushing was 107 times greater than a single tooth extraction (8). These and other studies suggest that the risk for bacteremia and subsequent IE from everyday activities is much higher than that from the occasional dental procedure (9).
*Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the Duke University Medical Center, Durham, North Carolina.
Importantly, specific indexes of oral hygiene (i.e., plaque, calculus, and gingival bleeding) have been correlated with risk for bacteremia (10). In the present
Dr. Chu has reported that she has no relationships relevant to the
study, 22% of patients had dental POEs. A thoughtful
contents of this paper to disclose.
discussion of which patients, when, and with what
160
Chu
JACC VOL. 67, NO. 2, 2016 JANUARY 19, 2016:159–61
Portals of Entry in Infective Endocarditis
particular antimicrobial agents (given present-day
as a Lancefield group D streptococcus, an entero-
patterns of antibiotic resistance) antibiotic prophy-
coccus, or simply as “S. bovis group,” these bacteria
laxis should be geared toward is beyond the scope of
have since been differentiated by deoxyribonucleic
this editorial. Nevertheless, not only dentists but also
acid sequencing as S. gallolyticus and S. infantarius. In
physicians should routinely advocate something as
the present study, 14% of patients with a GI POEs were
simple as maintenance of good oral hygiene.
also diagnosed with colorectal adenocarcinoma. The
Efforts to decrease intravascular catheter-related
present study joins a host of other studies that support
infections via evidence-based infection control mea-
the association between bacteremia or IE due to these
sures, such as the use of chlorhexidine, education in
pathogens and GI pathology: mostly colon cancer (15–
sterile techniques, and avoidance of femoral site
18) but also adenomatous polyps (19), diverticulosis
location, have led to a decline in these infections over
(16), and biliary lesions (16,18). Taken together, the
the past decade (11), but intravascular catheters are
evidence highlights the importance of distinguishing
still a major POE for infection. In this study, 18% of
S. bovis group microorganisms from the general bale of
cutaneous POEs were related to vascular access.
viridans group streptococci and searching for a culprit
Appropriate management of intravascular catheters in
GI source.
the setting of bacteremia (12) is essential for source control.
Delahaye et al.’s study on POE in IE is limited in generalizability by its single-center nature. In addi-
Another major problem to consider with cutaneous
tion, it relies on the most logical, but not necessarily
POEs is intravenous drug use. In this cohort, intra-
proven, POE and does not elaborate on the possibility
venous drug use accounted for 22% of cutaneous
of multiple POEs. However, from a practical and
POEs. Particularly in the United States, where the rate
clinical perspective, it is good to know that a sys-
of heroin abuse has skyrocketed to surprising levels
tematic search will likely yield an answer. The take-
(13), intravenous drug use–related cutaneous POEs
home message is that we can add an element of
may become a growing problem. Preventing addi-
prevention to the treatment plan for a potentially
tional episodes of IE is a special challenge in this
devastating disease.
population. Effective approaches to treatment must
Interestingly, only 1 case of cat scratch disease and
incorporate drug rehabilitation and social services;
IE due to Bartonella henselae was diagnosed in this
however, these approaches still need to be defined.
cohort, and we don’t know what happened to the cat.
STRENGTHENING THE CORRELATION BETWEEN INFECTIVE ENDOCARDITIS AND
With the diagnosis of IE, the cat’s out of the bag—but let’s try to prevent it from happening again.
GASTROINTESTINAL PATHOLOGY: KNOWING WHAT TO LOOK FOR—AND FINDING IT
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Vivian H. Chu, Duke University Medical Center, Box The link between Streptococcus bovis and colon cancer
102359, Hanes 177, Durham, North Carolina 27710.
was first described in 1951 (14). Previously categorized
E-mail: [email protected].
REFERENCES 1. Delahaye F, M’Hammedi A, Guerpillon B, et al.
guideline from the American Heart Association
8. Bahn SL, Goveia G, Bitterman P, et al. Experi-
Systematic search for present and potential portals of entry for infective endocarditis. J Am Coll Cardiol 2016;67:151–8.
Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2007;138:739–45, 747–60.
mental endocarditis induced by dental manipulation and oral streptococci. Oral Surg Oral Med Oral Pathol 1978;45:549–59.
2. Welton DE, Young JB, Gentry WO, et al. Recurrent infective endocarditis: analysis of predisposing factors and clinical features. Am J Med 1979;66:932–8. 3. Levison ME, Kaye D, Mandell GL, et al. Characteristics of patients with multiple episodes of bacterial endocarditis. JAMA 1970;211:1355–7. 4. Chu VH, Sexton DJ, Cabell CH, et al. Repeat infective endocarditis: differentiating relapse from reinfection. Clin Infect Dis 2005;41:406–9. 5. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: guidelines from the American Heart Association: a
6. Authors/Task Force Members, Habib G, Hoen B, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and by the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30:2369–413.
9. Roberts GJ. Dentists are innocent! “Everyday” bacteremia is the real culprit: a review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children. Pediatr Cardiol 1999;20: 317–25. 10. Lockhart PB, Brennan MT, Thornhill M, et al. Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. J Am Dent Assoc 2009;140:1238–44.
7. Roberts GJ, Radford P, Holt R. Prophylaxis of
11. Fagan RP, Edwards JR, Park BJ, et al. Incidence trends in pathogen-specific central line-associated bloodstream infections in US intensive care units
dental bacteraemia with oral amoxycillin in children. Br Dent J 1987;162:179–82.
1990–2010. Infect Control Hosp Epidemiol 2013; 34:893–9.
Chu
JACC VOL. 67, NO. 2, 2016 JANUARY 19, 2016:159–61
Portals of Entry in Infective Endocarditis
12. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases
15. Galdy S, Nastasi G. Streptococcus bovis endocarditis and colon cancer: myth or reality? A case report and literature review. BMJ Case Rep. Available at: http://casereports.bmj.com/content/2012/bcr-2
18. Fernandez-Ruiz M, Villar-Silva J, LlenasGarcia J, et al. Streptococcus bovis bacteraemia revisited: clinical and microbiological correlates in a contemporary series of 59 patients. J Infection
Society of America. Clin Infect Dis 2009;49:1–45.
012-006961.abstract. Accessed November 20, 2015.
2010;61:307–13.
13. Jones CM, Logan J, Gladden RM, et al. Vital signs: demographic and substance use trends among heroin users—United States 2002–2013. MMWR Morb Mortal Wkly Rep 2015;64:719–25.
16. Lazarovitch T, Shango M, Levine M, et al. The relationship between the new taxonomy of Streptococcus bovis and its clonality to colon cancer, endocarditis, and biliary disease. Infection
19. Klein RS, Catalano MT, Edberg SC, et al.
14. McCoy CW, Mason JM III Enterococcal endocarditis associated with carcinoma of the sigmoid; report of a case. J Med Assoc State Ala 1951;21:162–6.
17. Klein RS, Recco RA, Catalano MT, et al. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med 1977;297:800–2.
Streptococcus bovis septicemia and carcinoma of the colon. Ann Int Med 1979;91:560–2.
2013;41:329–37. KEY WORDS bacteremia, catheter-related infections, colorectal neoplasms, heart valves, oral hygiene, streptococcus
161
VOL. 67, NO. 2, 2016
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jacc.2015.10.066
EDITORIAL COMMENT
When the Cat’s Out of the Bag Searching for Portals of Entry in Infective Endocarditis* Vivian H. Chu, MD, MHS
I
nfective endocarditis (IE) often poses challenges
Furthermore, the investigators found that one-third
of the diagnostic and/or treatment variety. Take,
of patients had additional POEs that could serve as
for instance, the case of a 24-year-old man with
sources for new IE episodes. This study grapples with
congenital heart disease who is diagnosed with Barto-
the issue of source identification in patients with IE, a
nella henselae IE. Patient: “What’s the next step,
ubiquitous concern that has been sparsely addressed
doc?” Physician: “You will have a peripherally
in published medical research.
inserted central catheter in your arm through which
The identification of POEs and subsequent eradi-
you will receive intravenous antibiotics for 6 weeks.
cation of sources of infection is particularly important
This will be followed by at least 3 to 6 months of
in IE because having IE in the first place puts one at
oral antibiotics, potentially longer. These antibiotics
risk for subsequent IE. In the published research, the
may cause diarrhea. You will need to have your pace-
lifetime risk for a repeat episode of IE ranges from 2%
maker removed and then replaced. If your heart valve
to 30% (2,3). In a large multicenter cohort of patients
falters, you will need to have open heart surgery to
with IE, history of IE was an independent predictor of
replace your heart valve.” And now for the really
repeat IE (4), highlighting the importance of obtain-
bad news: “You have to give away your cat.sorry.”
ing timely source control in patients with IE.
SEE PAGE 151
In this issue of the Journal, Delahaye et al. (1) report the results of a single-center study examining portals of entry (POEs) in IE. In this study, a total of 318 patients hospitalized for IE between 2005 and 2011 were systematically evaluated by a dentist, ear, nose, and throat specialist, urologist (women were evaluated by a gynecologist), and, if indicated on examination, a dermatologist. Brain and body radiological
scans
were
systematically
performed.
A gastrointestinal (GI) evaluation, including colonoscopy and gastroscopy, was performed if the infecting pathogen was a GI microorganism and/or if the patient was $50 years of age or at high risk for colorectal cancer. POEs were identified in 74% of the patients. The largest group of POEs were cutaneous (40%), followed by oral or dental (29%) and GI (23%).
PREVENTION OF INFECTIVE ENDOCARDITIS: CAN WE DO MORE? The discussion surrounding IE prevention has evolved over time and, in the United States and Europe, focuses primarily on the use of antibiotic prophylaxis before dental procedures in high-risk patients (5,6). Patients with histories of IE fall into the high-risk category, making them eligible for antibiotic prophylaxis. Are we done here? According to 1 study, the intensity of bacteremia required to cause IE in an animal model was at least 4 orders of magnitude greater than the intensity of bacteremia after tooth extraction in humans (7). In another study, the cumulative exposure to bacteremia after tooth brushing was 107 times greater than a single tooth extraction (8). These and other studies suggest that the risk for bacteremia and subsequent IE from everyday activities is much higher than that from the occasional dental procedure (9).
*Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the Duke University Medical Center, Durham, North Carolina.
Importantly, specific indexes of oral hygiene (i.e., plaque, calculus, and gingival bleeding) have been correlated with risk for bacteremia (10). In the present
Dr. Chu has reported that she has no relationships relevant to the
study, 22% of patients had dental POEs. A thoughtful
contents of this paper to disclose.
discussion of which patients, when, and with what
160
Chu
JACC VOL. 67, NO. 2, 2016 JANUARY 19, 2016:159–61
Portals of Entry in Infective Endocarditis
particular antimicrobial agents (given present-day
as a Lancefield group D streptococcus, an entero-
patterns of antibiotic resistance) antibiotic prophy-
coccus, or simply as “S. bovis group,” these bacteria
laxis should be geared toward is beyond the scope of
have since been differentiated by deoxyribonucleic
this editorial. Nevertheless, not only dentists but also
acid sequencing as S. gallolyticus and S. infantarius. In
physicians should routinely advocate something as
the present study, 14% of patients with a GI POEs were
simple as maintenance of good oral hygiene.
also diagnosed with colorectal adenocarcinoma. The
Efforts to decrease intravascular catheter-related
present study joins a host of other studies that support
infections via evidence-based infection control mea-
the association between bacteremia or IE due to these
sures, such as the use of chlorhexidine, education in
pathogens and GI pathology: mostly colon cancer (15–
sterile techniques, and avoidance of femoral site
18) but also adenomatous polyps (19), diverticulosis
location, have led to a decline in these infections over
(16), and biliary lesions (16,18). Taken together, the
the past decade (11), but intravascular catheters are
evidence highlights the importance of distinguishing
still a major POE for infection. In this study, 18% of
S. bovis group microorganisms from the general bale of
cutaneous POEs were related to vascular access.
viridans group streptococci and searching for a culprit
Appropriate management of intravascular catheters in
GI source.
the setting of bacteremia (12) is essential for source control.
Delahaye et al.’s study on POE in IE is limited in generalizability by its single-center nature. In addi-
Another major problem to consider with cutaneous
tion, it relies on the most logical, but not necessarily
POEs is intravenous drug use. In this cohort, intra-
proven, POE and does not elaborate on the possibility
venous drug use accounted for 22% of cutaneous
of multiple POEs. However, from a practical and
POEs. Particularly in the United States, where the rate
clinical perspective, it is good to know that a sys-
of heroin abuse has skyrocketed to surprising levels
tematic search will likely yield an answer. The take-
(13), intravenous drug use–related cutaneous POEs
home message is that we can add an element of
may become a growing problem. Preventing addi-
prevention to the treatment plan for a potentially
tional episodes of IE is a special challenge in this
devastating disease.
population. Effective approaches to treatment must
Interestingly, only 1 case of cat scratch disease and
incorporate drug rehabilitation and social services;
IE due to Bartonella henselae was diagnosed in this
however, these approaches still need to be defined.
cohort, and we don’t know what happened to the cat.
STRENGTHENING THE CORRELATION BETWEEN INFECTIVE ENDOCARDITIS AND
With the diagnosis of IE, the cat’s out of the bag—but let’s try to prevent it from happening again.
GASTROINTESTINAL PATHOLOGY: KNOWING WHAT TO LOOK FOR—AND FINDING IT
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Vivian H. Chu, Duke University Medical Center, Box The link between Streptococcus bovis and colon cancer
102359, Hanes 177, Durham, North Carolina 27710.
was first described in 1951 (14). Previously categorized
E-mail: [email protected].
REFERENCES 1. Delahaye F, M’Hammedi A, Guerpillon B, et al.
guideline from the American Heart Association
8. Bahn SL, Goveia G, Bitterman P, et al. Experi-
Systematic search for present and potential portals of entry for infective endocarditis. J Am Coll Cardiol 2016;67:151–8.
Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2007;138:739–45, 747–60.
mental endocarditis induced by dental manipulation and oral streptococci. Oral Surg Oral Med Oral Pathol 1978;45:549–59.
2. Welton DE, Young JB, Gentry WO, et al. Recurrent infective endocarditis: analysis of predisposing factors and clinical features. Am J Med 1979;66:932–8. 3. Levison ME, Kaye D, Mandell GL, et al. Characteristics of patients with multiple episodes of bacterial endocarditis. JAMA 1970;211:1355–7. 4. Chu VH, Sexton DJ, Cabell CH, et al. Repeat infective endocarditis: differentiating relapse from reinfection. Clin Infect Dis 2005;41:406–9. 5. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: guidelines from the American Heart Association: a
6. Authors/Task Force Members, Habib G, Hoen B, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and by the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30:2369–413.
9. Roberts GJ. Dentists are innocent! “Everyday” bacteremia is the real culprit: a review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children. Pediatr Cardiol 1999;20: 317–25. 10. Lockhart PB, Brennan MT, Thornhill M, et al. Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. J Am Dent Assoc 2009;140:1238–44.
7. Roberts GJ, Radford P, Holt R. Prophylaxis of
11. Fagan RP, Edwards JR, Park BJ, et al. Incidence trends in pathogen-specific central line-associated bloodstream infections in US intensive care units
dental bacteraemia with oral amoxycillin in children. Br Dent J 1987;162:179–82.
1990–2010. Infect Control Hosp Epidemiol 2013; 34:893–9.
Chu
JACC VOL. 67, NO. 2, 2016 JANUARY 19, 2016:159–61
Portals of Entry in Infective Endocarditis
12. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases
15. Galdy S, Nastasi G. Streptococcus bovis endocarditis and colon cancer: myth or reality? A case report and literature review. BMJ Case Rep. Available at: http://casereports.bmj.com/content/2012/bcr-2
18. Fernandez-Ruiz M, Villar-Silva J, LlenasGarcia J, et al. Streptococcus bovis bacteraemia revisited: clinical and microbiological correlates in a contemporary series of 59 patients. J Infection
Society of America. Clin Infect Dis 2009;49:1–45.
012-006961.abstract. Accessed November 20, 2015.
2010;61:307–13.
13. Jones CM, Logan J, Gladden RM, et al. Vital signs: demographic and substance use trends among heroin users—United States 2002–2013. MMWR Morb Mortal Wkly Rep 2015;64:719–25.
16. Lazarovitch T, Shango M, Levine M, et al. The relationship between the new taxonomy of Streptococcus bovis and its clonality to colon cancer, endocarditis, and biliary disease. Infection
19. Klein RS, Catalano MT, Edberg SC, et al.
14. McCoy CW, Mason JM III Enterococcal endocarditis associated with carcinoma of the sigmoid; report of a case. J Med Assoc State Ala 1951;21:162–6.
17. Klein RS, Recco RA, Catalano MT, et al. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med 1977;297:800–2.
Streptococcus bovis septicemia and carcinoma of the colon. Ann Int Med 1979;91:560–2.
2013;41:329–37. KEY WORDS bacteremia, catheter-related infections, colorectal neoplasms, heart valves, oral hygiene, streptococcus
161