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BACKGROUND: The safety of adding initial low-dose gentamicin to antistaphylococcal penicillins or vancomycin for treatment of suspected Staphylococcus aureus native valve endocarditis is unknown. This study evaluated the association between this practice and nephrotoxicity. METHODS: We performed a prospective cohort study of safety data from a randomized, controlled trial of therapy for S. aureus bacteremia and native valve infective endocarditis involving 236 patients from 44 hospitals in 4 countries. Patients either received standard therapy (antistaphylococcal penicillin or vancomycin) plus initial low-dose gentamicin (n=116) or received daptomycin monotherapy (n = 120). We measured renal adverse events and clinically significant decreased creatinine clearance in patients (1) in the original randomized study arms and (2) who received any initial low-dose gentamicin either, as a study medication or
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Antibacterianos/efectos adversos , Bacteriemia/tratamiento farmacológico , Endocarditis Bacteriana/tratamiento farmacológico , Gentamicinas/efectos adversos , Riñón/efectos de los fármacos , Infecciones Estafilocócicas/tratamiento farmacológico , Staphylococcus aureus/efectos de los fármacos , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/administración & dosificación , Antibacterianos/uso terapéutico , Estudios de Cohortes , Creatinina/sangre , Daptomicina/uso terapéutico , Quimioterapia Combinada , Femenino , Gentamicinas/administración & dosificación , Gentamicinas/uso terapéutico , Humanos , Masculino , Tasa de Depuración Metabólica , Persona de Mediana Edad , Penicilinas/uso terapéutico , Estudios Prospectivos , Staphylococcus aureus/aislamiento & purificación , Vancomicina/uso terapéutico , Adulto JovenRESUMEN
OBJECTIVES: In a prospective, randomized trial, daptomycin was non-inferior to standard therapy for Staphylococcus aureus bacteraemia and right-sided endocarditis. Since rates of infection due to methicillin-resistant S. aureus (MRSA) infection are increasing and treatment outcomes for bacteraemia caused by MRSA are generally worse than those observed with methicillin-susceptible S. aureus bacteraemia, clinical characteristics and treatment results in the trial's pre-specified subset of patients with MRSA were analysed. METHODS: Clinical characteristics and outcomes of patients receiving daptomycin were compared with those receiving vancomycin plus low-dose gentamicin. Success was defined as clinical improvement with clearance of bacteraemia among patients who completed adequate therapy, received no potentially effective non-study antibiotics and had negative blood cultures 6 weeks after end of therapy. RESULTS: Twenty of the 45 (44.4%) daptomycin patients and 14 of the 43 (32.6%) vancomycin/gentamicin patients were successfully treated (difference 11.9%; confidence interval -8.3 to 32.1). Success rates for daptomycin versus vancomycin/gentamicin were 45% versus 27% in complicated bacteraemia, 60% versus 45% in uncomplicated bacteraemia and 50% versus 50% in right-sided MRSA endocarditis. Cure rates in patients with septic emboli and in patients who received pre-enrolment vancomycin were similar between treatment groups. However, in both treatment groups, success rates were lower in the elderly (>/=75 years). Persisting or relapsing bacteraemia occurred in 27% of daptomycin and 21% of vancomycin/gentamicin patients; among these patients, MICs of >/=2 mg/L occurred in five daptomycin and four vancomycin/gentamicin patients. The clinical course of several patients may have been influenced by lack of surgical intervention. CONCLUSIONS: Daptomycin was an effective alternative to vancomycin/gentamicin for MRSA bacteraemia or right-sided endocarditis.
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Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Daptomicina/uso terapéutico , Endocarditis Bacteriana/tratamiento farmacológico , Gentamicinas/uso terapéutico , Infecciones Estafilocócicas/tratamiento farmacológico , Vancomicina/uso terapéutico , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Antibacterianos/farmacología , Daptomicina/farmacología , Femenino , Gentamicinas/farmacología , Humanos , Masculino , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Estudios Prospectivos , Infecciones Estafilocócicas/microbiología , Resultado del Tratamiento , Vancomicina/farmacologíaRESUMEN
BACKGROUND: Embolic events to the central nervous system are a major cause of morbidity and mortality in patients with infective endocarditis (IE). The appropriate role of valvular surgery in reducing such embolic events is unclear. The purpose of this study was to determine the relationship between the initiation of antimicrobial therapy and the temporal incidence of stroke in patients with IE and to determine if this time course differs from that shown for embolic events in previous studies. METHODS: Prospective incidence cohort study involving 61 tertiary referral centers in 28 countries. Case report forms were analyzed from 1437 consecutive patients with left-sided endocarditis admitted directly to participating centers. RESULTS: The crude incidence of stroke in patients receiving appropriate antimicrobial therapy was 4.82/1000 patient days in the first week of therapy and fell to 1.71/1000 patient days in the second week. This rate continued to decline with further therapy. Stroke rates fell similarly regardless of the valve or organism involved. After 1 week of antimicrobial therapy, only 3.1% of the cohort experienced a stroke. CONCLUSIONS: The risk of stroke in IE falls dramatically after the initiation of effective antimicrobial therapy. The falling risk of stroke in patients with IE as a whole precludes stroke prevention as the sole indication for valvular surgery after 1 week of therapy.
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Antiinfecciosos/uso terapéutico , Endocarditis Bacteriana/complicaciones , Accidente Cerebrovascular/epidemiología , Anciano , Análisis de Varianza , Estudios de Cohortes , Endocarditis Bacteriana/tratamiento farmacológico , Endocarditis Bacteriana/microbiología , Femenino , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Accidente Cerebrovascular/etiologíaRESUMEN
Propionibacterium species are occasionally associated with serious systemic infections such as infective endocarditis. In this study, we examined the clinical features, complications and outcome of 15 patients with Propionibacterium endocarditis using the International Collaboration on Endocarditis Merged Database (ICE-MD) and Prospective Cohort Study (ICE-PCS), and compared the results to 28 cases previously reported in the literature. In the ICE database, 11 of 15 patients were male with a mean age of 52 y. Prosthetic valve endocarditis occurred in 13 of 15 cases and 3 patients had a history of congenital heart disease. Clinical findings included valvular vegetations (9 patients), cardiac abscesses (3 patients), congestive heart failure (2 patients), and central nervous system emboli (2 patients). Most patients were treated with beta-lactam antibiotics alone or in combination for 4 to 6 weeks. 10 of the 15 patients underwent valve replacement surgery and 2 patients died. Similar findings were noted on review of the literature. The results of this paper suggest that risk factors for Propionibacterium endocarditis include male gender, presence of prosthetic valves and congenital heart disease. The clinical course is characterized by complications such as valvular dehiscence, cardiac abscesses and congestive heart failure. Treatment may require a combination of medical and surgical therapy.
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Infecciones por Actinomycetales , Endocarditis Bacteriana , Propionibacterium , Infecciones por Actinomycetales/complicaciones , Infecciones por Actinomycetales/epidemiología , Infecciones por Actinomycetales/microbiología , Infecciones por Actinomycetales/fisiopatología , Adulto , Anciano , Estudios de Cohortes , Bases de Datos Factuales , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/epidemiología , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/fisiopatología , Femenino , Cardiopatías/complicaciones , Cardiopatías/congénito , Cardiopatías/epidemiología , Cardiopatías/microbiología , Prótesis Valvulares Cardíacas/microbiología , Humanos , Cooperación Internacional , Masculino , Persona de Mediana Edad , Pronóstico , Propionibacterium/clasificación , Propionibacterium/aislamiento & purificación , Estudios Prospectivos , Infecciones Relacionadas con Prótesis/complicaciones , Infecciones Relacionadas con Prótesis/epidemiología , Infecciones Relacionadas con Prótesis/microbiología , Infecciones Relacionadas con Prótesis/fisiopatología , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
Infective endocarditis (IE) remains a serious and deadly disease. The incidence, which varies by gender and on the presence of predisposing factors, has not decreased, due in part to the aging population with more healthcare exposures and predisposing risk factors such as prosthetic heart valves and intracardiac devices. The most important aspects of treatment in IE hinge upon early diagnosis, microorganism identification with susceptibility testing, and early initiation of appropriate antibiotic therapy. In addition, echocardiographic imaging is critical for both diagnostic and prognostic purposes. Early evaluation for surgery should be considered. Once a therapeutic strategy is begun, careful attention to the clinical course is necessary to ensure appropriate response to therapy and to identify complications early.
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BACKGROUND: Influenza vaccination has been shown to reduce illness and all-cause mortality in vulnerable populations through the prevention of influenza infection. Attenuation of the severity of illness by vaccination has been reported for respiratory tract infections due to bacterial pathogens and would represent an important additional health benefit of influenza vaccination. We evaluated the impact of prior influenza vaccination on in-hospital mortality and other health outcomes among hospitalized adults with community-acquired pneumonia (CAP). METHODS: Consecutive individuals hospitalized with CAP during "influenza season" (November to April, 1999-2003) at hospitals operated by Tenet HealthCare were identified using a database constructed to improve quality of patient care. Associations between vaccination status and all-cause in-hospital mortality were evaluated using logistic regression models. RESULTS: Among 17 393 adults hospitalized with CAP during the study period, 1590 (19% of those with recorded vaccine status) had a history of influenza vaccination in the current or most recent influenza season. Vaccine recipients were less likely to die in hospital of any cause than individuals without vaccination (odds ratio, 0.30; 95% confidence interval, 0.22-0.41). These effects remained significant after adjustment for the presence of comorbid illnesses and pneumococcal vaccination (adjusted odds ratio for death, 0.61; 95% confidence interval, 0.43-0.87) and under widely varying assumptions about individuals with missing vaccination status. CONCLUSIONS: Prior influenza vaccination was associated with improved survival in hospitalized patients with CAP during influenza season. This observation, if confirmed by other studies, would represent an important additional benefit of enhanced influenza vaccine coverage.
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Infecciones Comunitarias Adquiridas/mortalidad , Vacunas contra la Influenza/administración & dosificación , Gripe Humana/prevención & control , Neumonía Bacteriana/mortalidad , Vacunación , Anciano , Infecciones Comunitarias Adquiridas/complicaciones , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Gripe Humana/complicaciones , Pacientes Internos , Masculino , Oportunidad Relativa , Neumonía Bacteriana/complicaciones , Estudios Retrospectivos , Factores de Riesgo , Texas/epidemiologíaRESUMEN
BACKGROUND: Alternative therapies for Staphylococcus aureus bacteremia and endocarditis are needed. METHODS: We randomly assigned 124 patients with S. aureus bacteremia with or without endocarditis to receive 6 mg of daptomycin intravenously per kilogram of body weight daily and 122 to receive initial low-dose gentamicin plus either an antistaphylococcal penicillin or vancomycin. The primary efficacy end point was treatment success 42 days after the end of therapy. RESULTS: Forty-two days after the end of therapy in the modified intention-to-treat analysis, a successful outcome was documented for 53 of 120 patients who received daptomycin as compared with 48 of 115 patients who received standard therapy (44.2 percent vs. 41.7 percent; absolute difference, 2.4 percent; 95 percent confidence interval, -10.2 to 15.1 percent). Our results met prespecified criteria for the noninferiority of daptomycin. The success rates were similar in subgroups of patients with complicated bacteremia, right-sided endocarditis, and methicillin-resistant S. aureus. Daptomycin therapy was associated with a higher rate of microbiologic failure than was standard therapy (19 vs. 11 patients, P=0.17). In 6 of the 19 patients with microbiologic failure in the daptomycin group, isolates with reduced susceptibility to daptomycin emerged; similarly, a reduced susceptibility to vancomycin was noted in isolates from patients treated with vancomycin. As compared with daptomycin therapy, standard therapy was associated with a nonsignificantly higher rate of adverse events that led to treatment failure due to the discontinuation of therapy (17 vs. 8, P=0.06). Clinically significant renal dysfunction occurred in 11.0 percent of patients who received daptomycin and in 26.3 percent of patients who received standard therapy (P=0.004). CONCLUSIONS: Daptomycin (6 mg per kilogram daily) is not inferior to standard therapy for S. aureus bacteremia and right-sided endocarditis. (ClinicalTrials.gov number, NCT00093067 [ClinicalTrials.gov].).
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Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Daptomicina/uso terapéutico , Endocarditis Bacteriana/tratamiento farmacológico , Infecciones Estafilocócicas/tratamiento farmacológico , Adulto , Anciano , Anciano de 80 o más Años , Bacteriemia/microbiología , Endocarditis Bacteriana/microbiología , Femenino , Gentamicinas/uso terapéutico , Humanos , Masculino , Resistencia a la Meticilina , Persona de Mediana Edad , Penicilinas/uso terapéutico , Infecciones Estafilocócicas/microbiología , Staphylococcus aureus/efectos de los fármacos , Resultado del Tratamiento , Vancomicina/uso terapéuticoRESUMEN
The purpose of this investigation was to study the influence of diabetes mellitus (DM) on outcomes of infective endocarditis (IE). Outcomes were compared between 150 diabetic and 905 non-diabetic patients with IE from the International Collaboration on Endocarditis Merged Database. Compared to non-diabetic patients, diabetic patients were older (median age 63 vs 57 y, p<0.001), were more often female (42.0% vs 31.9%, p=0.01), more often had comorbidities (41.5% vs 26.7%, p<0.001), and were more likely to be dialysis dependent (12.7% vs 4.0%, p<0.001). S. aureus was isolated more often (30.7% vs 21.7%, p=0.02), and microorganisms from the viridans Streptococcus group less often (16.7% vs 28.2%, p = 0.001) in the diabetic group. There was no difference with respect to the presence of congestive heart failure, embolism, intra-cardiac abscess, new valvular regurgitation, or valvular vegetation. Diabetic patients underwent surgical intervention less frequently (32.0% vs 44.9%, p = 0.003), and had higher overall in-hospital mortality (30.3% vs 18.6%, p = 0.001). On multivariable analysis, DM was an independent predictor of mortality (odds ratio (OR) = 1.71, 95% confidence interval (CI) 1.08-2.70), especially in male patients, as diabetic males had higher mortality than non-diabetic males (OR 2.18, CI 1.08-4.35). DM is an independent predictor of in-hospital mortality among patients hospitalized with IE.
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Diabetes Mellitus/microbiología , Endocarditis/complicaciones , Anciano , Diabetes Mellitus/epidemiología , Ecocardiografía , Endocarditis/epidemiología , Europa (Continente)/epidemiología , Femenino , Insuficiencia Cardíaca/epidemiología , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Infecciones Estafilocócicas/complicaciones , Infecciones Estafilocócicas/epidemiología , Staphylococcus aureus/aislamiento & purificación , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Vaccination with pneumococcal polysaccharide reduces the incidence of bacteremic pneumococcal disease in adults. We investigated the impact of prior pneumococcal vaccination on in-hospital mortality and the probability of respiratory failure among hospitalized adults with community-acquired pneumonia. METHODS: Consecutive individuals hospitalized with community-acquired pneumonia (diagnosed by International Classification of Diseases, Ninth Revision, Clinical Modification codes 480.0-487.0) at 109 community and teaching hospitals in the United States were identified using the Quality and Resource Management System, a database constructed by Tenet HealthCare to improve the quality of patient care. Vaccination status, comorbidities, and outcomes were abstracted by case managers concurrently with patient care. Associations between vaccination, survival, and respiratory failure were defined using multivariable logistic regression models. RESULTS: Of 62,918 adults hospitalized with community-acquired pneumonia between 1999 and 2003, 7390 (12%) had a record of prior pneumococcal vaccination. Vaccine recipients were less likely to die of any cause during hospitalization than were individuals with no record of vaccination (adjusted odds ratio [OR], 0.50; 95% confidence interval [CI], 0.43-0.59), even after adjustment for the presence of comorbid illnesses, age, smoking, and influenza vaccination and under varying assumptions about missing vaccination data. Vaccination also lowered the risk of respiratory failure (adjusted OR, 0.67; 95% CI, 0.59-0.76) and other complications and reduced median length of stay by 2 days, compared with nonvaccination (P<.001). CONCLUSIONS: Prior vaccination against pneumococcus is associated with improved survival, decreased chance of respiratory failure or other complications, and decreased length of stay among hospitalized patients with community-acquired pneumonia. These observations reinforce current efforts to improve compliance with existing pneumococcal vaccination recommendations for adults.
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Bacteriemia/prevención & control , Infecciones Comunitarias Adquiridas/inmunología , Infecciones Neumocócicas/inmunología , Vacunas Neumococicas/uso terapéutico , Adulto , Infecciones Comunitarias Adquiridas/mortalidad , Humanos , Pacientes Internos , Tiempo de Internación , Infecciones Neumocócicas/mortalidad , Resultado del TratamientoAsunto(s)
Antibacterianos/efectos adversos , Enfermedad Hepática Inducida por Sustancias y Drogas/etiología , Cetólidos/efectos adversos , Inhibidores de la Síntesis de la Proteína/efectos adversos , Antibacterianos/farmacología , Humanos , Cetólidos/farmacología , Inhibidores de la Síntesis de la Proteína/farmacologíaRESUMEN
BACKGROUND: Although surgical intervention is often used in the treatment of prosthetic valve infective endocarditis (PVIE), an understanding of its effect on survival has been limited by the biases of observational studies and lack of controlled trials. METHODS: The International Collaboration on Endocarditis Merged Database is a large, multicenter, international registry of patients with definite endocarditis by Duke criteria, including 367 patients with PVIE. Clinical, microbiologic, and echocardiographic variables were analyzed to determine those factors associated with the use of surgery for PVIE. Logistic regression analysis was performed to create a propensity model of predictors of surgery use. Patients who underwent surgery during initial hospitalization were matched by propensity score with patients treated with medical therapy alone. Logistic regression analysis was performed to determine variables independently associated with inhospital mortality in this matched subset. RESULTS: Surgical therapy for PVIE was performed in 148 (42%) of 367 patients. Inhospital mortality was similar for patients treated with surgery compared with those treated with medical therapy alone (25.0% vs 23.4%, P = .729). Surgical therapy was independently associated with patient age, microorganism, intracardiac abscess, and congestive heart failure. After adjustment for these determinants, inhospital mortality was predicted by brain embolization (OR 11.12, 95% CI 4.16-29.73) and Staphylococcus aureus infection (OR 3.67, 95% CI 1.29-9.74), with a trend toward benefit for surgery (OR 0.56, 95% CI 0.23-1.36). CONCLUSIONS: Despite the frequent use of surgery for the treatment of PVIE, this condition continues to be associated with a high inhospital mortality rate in the contemporary era. After adjustment for factors related to surgical intervention, brain embolism and S aureus infection were independently associated with inhospital mortality and a trend toward a survival benefit of surgery was evident.
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Endocarditis Bacteriana/cirugía , Prótesis Valvulares Cardíacas/efectos adversos , Infecciones Relacionadas con Prótesis/cirugía , Anciano , Estudios de Cohortes , Endocarditis Bacteriana/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/mortalidadRESUMEN
BACKGROUND: Early surgery has been shown to be beneficial for patients with infective endocarditis (IE), yet surgery is not used in most patients. Evidence of the uncertainty around the use of surgery can be found in the wide variations in the use of cardiac surgery in IE with few precise indications for cardiac surgery yet defined. The aim of the study was to characterize patients with native valve IE relative to surgery and to determine if patients who benefit from an early surgical intervention can be identified. METHODS: The International Collaboration on Endocarditis Merged Database was used to quantify the differences between patients with IE receiving medical and surgical intervention in 1516 patients with definite native valve IE. Propensity models were built to identify a group of patients that benefit from early surgery. RESULTS: Patients in the early surgical group were more likely to be male, younger, and with less comorbidities compared with the early medical group (P < .001 for all) and were less likely to have infection with Staphylococcus aureus or viridans group streptococci (P < .05 for all). Intracardiac abscess and heart failure were much more common in the surgical group (P < .001 for all). In an unadjusted comparison, there was no statistically significant survival advantage in the surgical group. However, in the propensity analysis, in the subgroup of patients with the most indications for surgery, there was a significant decrease in mortality associated with early surgery (11.2% vs 38.0%, P < .001). CONCLUSIONS: The benefits of surgery are not seen uniformly in all patients with native valve IE, but are most realized in a targeted population. This observation requires confirmation in other populations of patients with definite IE.
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Endocarditis Bacteriana/cirugía , Enfermedades de las Válvulas Cardíacas/diagnóstico , Femenino , Enfermedades de las Válvulas Cardíacas/microbiología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The aims of this study were to determine the clinical characteristics and outcome of patients who had definite infective endocarditis (IE) complicated by aortic ring abscess formation that was detected with transesophageal echocardiography (TEE) and to determine the prognostic significance of abscess formation in aortic valve IE. Patients who had aortic valve IE were selected from the International Collaboration on Endocarditis Merged Database (ICE-MD) if they underwent TEE. Among 311 patients who had definite aortic valve IE, 67 (22%) had periannular abscesses. They were more likely to have infection in the setting of a prosthetic valve (40% vs 19%, p <0.001) and coagulase-negative staphylococcal IE (18% vs 6%, p < 0.01) and less likely to have streptococcal IE than were patients who did not develop abscess (28% vs 46%, p = 0.01). Systemic embolization, central nervous system events, and heart failure did not differ between those who developed abscess and those who did not, but power was limited. Patients who had abscess were more likely to undergo surgery (84% vs 36%, p <0.001), and their in-hospital mortality rate was higher (19% vs 11%, p = 0.09). Multivariate analysis of prognostic factors of mortality in aortic IE identified age (odds ratio [OR] 1.6, 95% confidence interval [CI]1.2 to 2.1), Staphylococcus aureus (S. aureus) infection (OR 2.4, 95% CI 1.1 to 5.2), and heart failure (OR 2.9, 95% CI 1.4 to 6.1) as variables that were independently associated with increased risk of death. Periannular abscess formation showed a nonsignificant trend toward an increased risk of death (OR 1.9, 95% CI 0.9 to 3.8). Multivariate analysis of prognostic factors of mortality in complicated aortic IE with abscess formation identified S. aureus infection (OR 6.9, 95% CI 1.6 to 29.4) as independently associated with increased risk of death. In conclusion, in the current era of TEE and high use of surgical treatment, periannular abscess formation in aortic valve IE is not an independent risk factor for mortality. S. aureus infection is an independent prognostic factor for mortality in patients who have abscess formation.
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Absceso/complicaciones , Válvula Aórtica , Endocarditis Bacteriana/complicaciones , Enfermedades de las Válvulas Cardíacas/complicaciones , Absceso/microbiología , Absceso/mortalidad , Ecocardiografía Transesofágica , Endocarditis Bacteriana/diagnóstico por imagen , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidad , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/microbiología , Enfermedades de las Válvulas Cardíacas/mortalidad , Prótesis Valvulares Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Infecciones Relacionadas con Prótesis/diagnóstico , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
BACKGROUND: Staphylococcus aureus native valve infective endocarditis (SA-NVIE) is not completely understood. The objective of this investigation was to describe the characteristics of a large, international cohort of patients with SA-NVIE. METHODS: The International Collaboration on Endocarditis Merged Database (ICE-MD) is a combination of 7 existing electronic databases from 5 countries that contains data on 2212 cases of definite infective endocarditis (IE). RESULTS: Of patients with native valve IE, 566 patients [corrected] had IE due to S. aureus, and 1074 patients had IE due to pathogens other than S. aureus (non-SA-NVIE). Patients with S. aureus IE were more likely to die (20% vs. 12%; P < .001), to experience an embolic event (61% [corrected] vs. 31%; P < .001), or to have a central nervous system event (21% [corrected] vs. 13%; P < .001) and were less likely to undergo surgery (26% vs. 39%; P < .001) than were patients with non-SA-NVIE. Multivariate analysis of prognostic factors of mortality identified age (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.7), periannular abscess (OR, 2.4; 95% CI, 1.0 [corrected] -5.6), heart failure (OR, 3.9; 95% CI, 2.3-6.7), and absence of surgical therapy (OR, 2.3; 95% CI, 1.3-4.2) as variables that were independently associated with mortality in patients with SA-NVIE. After adjusting for patient-, pathogen-, and treatment-specific characteristics by multivariate analysis, geographical region was also found to be associated with mortality in patients with SA-NVIE (P < .001). CONCLUSIONS: S. aureus is an important and common cause of IE. The outcome of SA-NVIE is worse than that of non-SA-NVIE. Several clinical parameters are independently associated with mortality for patients with SA-NVIE. The clinical characteristics and outcome of SA-NVIE vary significantly by geographic region, although the reasons for such regional variations in outcomes of SA-NVIE are unknown and are probably multifactorial. A large, prospective, multinational cohort study of patients with IE is now under way to further investigate these observations.
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Endocarditis Bacteriana/epidemiología , Endocarditis Bacteriana/microbiología , Infecciones Estafilocócicas/epidemiología , Bases de Datos como Asunto , Humanos , Resistencia a la Meticilina , Pronóstico , Factores de Riesgo , Staphylococcus aureusRESUMEN
CONTEXT: The global significance of infective endocarditis (IE) caused by Staphylococcus aureus is unknown. OBJECTIVES: To document the international emergence of health care-associated S aureus IE and methicillin-resistant S aureus (MRSA) IE and to evaluate regional variation in patients with S aureus IE. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational cohort study set in 39 medical centers in 16 countries. Participants were a population of 1779 patients with definite IE as defined by Duke criteria who were enrolled in the International Collaboration on Endocarditis-Prospective Cohort Study from June 2000 to December 2003. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: S aureus was the most common pathogen among the 1779 cases of definite IE in the International Collaboration on Endocarditis Prospective-Cohort Study (558 patients, 31.4%). Health care-associated infection was the most common form of S aureus IE (218 patients, 39.1%), accounting for 25.9% (Australia/New Zealand) to 54.2% (Brazil) of cases. Most patients with health care-associated S aureus IE (131 patients, 60.1%) acquired the infection outside of the hospital. MRSA IE was more common in the United States (37.2%) and Brazil (37.5%) than in Europe/Middle East (23.7%) and Australia/New Zealand (15.5%, P<.001). Persistent bacteremia was independently associated with MRSA IE (odds ratio, 6.2; 95% confidence interval, 2.9-13.2). Patients in the United States were most likely to be hemodialysis dependent, to have diabetes, to have a presumed intravascular device source, to receive vancomycin, to be infected with MRSA, and to have persistent bacteremia (P<.001 for all comparisons). CONCLUSIONS: S aureus is the leading cause of IE in many regions of the world. Characteristics of patients with S aureus IE vary significantly by region. Further studies are required to determine the causes of regional variation.
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Infección Hospitalaria/epidemiología , Endocarditis Bacteriana/epidemiología , Infecciones Estafilocócicas/epidemiología , Staphylococcus aureus , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/mortalidad , Salud Global , Mortalidad Hospitalaria , Humanos , Resistencia a la Meticilina , Estudios Prospectivos , Infecciones Estafilocócicas/microbiología , Infecciones Estafilocócicas/mortalidad , Staphylococcus aureus/efectos de los fármacosRESUMEN
Using a large cohort of patients from the International Collaboration on Endocarditis Merged Database, we compared coagulase-negative staphylococcal (CoNS) native-valve endocarditis (NVE) to NVE caused by more common pathogens. Rates of heart failure and mortality were similar between patients with CoNS NVE and patients with Staphylococcus aureus NVE, but rates for both groups were significantly higher than rates for patients with NVE due to viridans streptococci. These results emphasize the importance of CoNS as a cause of NVE and the potential for serious complications with this infection.
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Endocarditis Bacteriana/microbiología , Enfermedades de las Válvulas Cardíacas/microbiología , Infecciones Estafilocócicas , Anciano , Endocarditis Bacteriana/epidemiología , Femenino , Enfermedades de las Válvulas Cardíacas/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Infecciones Estafilocócicas/epidemiologíaAsunto(s)
Vacunas contra la Influenza/uso terapéutico , Gripe Humana/prevención & control , Vacunación Masiva/tendencias , Infecciones Neumocócicas/prevención & control , Vacunas Neumococicas/uso terapéutico , Adolescente , Adulto , Anciano , Niño , Preescolar , Humanos , Lactante , Recién Nacido , Control de Infecciones/métodos , Control de Infecciones/estadística & datos numéricos , Gripe Humana/tratamiento farmacológico , Vacunación Masiva/estadística & datos numéricos , Persona de Mediana Edad , Personal de Hospital/estadística & datos numéricos , Infecciones Neumocócicas/tratamiento farmacológico , Estados UnidosRESUMEN
Candida infective endocarditis (IE) is increasingly common, yet most reports have been single-center reviews. We evaluated 16 patients with Candida IE nested within a cohort of 2,022 patients with IE. Prosthetic valve IE was more common in patients with Candida (50% vs 17%); mortality was 37% for patients with Candida.
Asunto(s)
Candida/aislamiento & purificación , Candidiasis , Bases de Datos Factuales , Endocarditis , Cooperación Internacional , Sangre/microbiología , Candidiasis/epidemiología , Candidiasis/microbiología , Candidiasis/mortalidad , Estudios de Cohortes , Medios de Cultivo , Endocarditis/epidemiología , Endocarditis/microbiología , Endocarditis/mortalidad , Prótesis Valvulares Cardíacas/microbiología , Humanos , Lactante , Persona de Mediana Edad , Infecciones Relacionadas con Prótesis/microbiologíaRESUMEN
Resistance to antimicrobial drugs is increasing at an alarming rate among both gram-positive and gram-negative bacteria. Traditionally, bacteria resistant to multiple antimicrobial agents have been restricted to the nosocomial environment. A disturbing trend has been the recent emergence and spread of resistant pathogens and resistance traits in nursing homes, the community, as well as in hospitals. This article reviews the epidemiology, molecular mechanisms of resistance, and treatment options for pathogens resistant to antimicrobial drugs.