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Query: UMLS:C0014118 (endocarditis)
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Although the sensitivity and specificity of the Duke criteria for the diagnosis of infective endocarditis (IE) have been validated by investigators from Europe and the United States, several shortcomings of this schema remain. The Duke IE database contains records collected prospectively on >800 cases of definite and possible IE since 1984. Databases on echocardiograms and on patients with Staphylococcus aureus bacteremia at Duke University Medical Center are also maintained. Analyses of these databases, our experience with the Duke criteria in clinical practice, and analysis of the work of others have led us to propose the following modifications of the Duke schema. The category "possible IE" should be defined as having at least 1 major criterion and 1 minor criterion or 3 minor criteria. The minor criterion "echocardiogram consistent with IE but not meeting major criterion" should be eliminated, given the widespread use of transesophageal echocardiography (TEE). Bacteremia due to S. aureus should be considered a major criterion, regardless of whether the infection is nosocomially acquired or whether a removable source of infection is present. Positive Q-fever serology should be changed to a major criterion.
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PMID:Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. 1077 Jul 21

Staphylococcus aureus bacteremia is a serious and common disease often associated with infective endocarditis. It occurs in both healthy, immunologically competent people in the community and compromised patients in the hospitals. For S. aureus bacteremia, questions on clinical issues such as antimicrobial treatment are raised. Is nafcillin/oxacillin superior to vancomycin? Does the addition of rifampin improve outcome? Does addition of aminoglycoside improve the outcome? Does increasing duration of therapy (> 4 weeks versus < 2 weeks) improve outcome? How many cases of community-acquired S. aureus bacteremia have endocarditis on admission? What are the risk factors that would separate bacteremia from endocarditis? What is the role of echocardiography? What are the indications for routine echocardiography? Are methicillin-resistant S. aureus (MRSA) more virulent than methicillin-susceptible S. aureus (MSSA)? What factors predict mortality in S. aureus bacteremia? Herein, the above important issues on S. aureus bacteremia and endocarditis are critically reviewed.
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PMID:Staphylococcus aureus bacteremia and endocarditis. 1091 74

Staphylococcus aureus bacteremia (SAB) is a serious and growing problem. A longstanding controversy in infectious diseases has centered around the duration of therapy for patients with SAB. Fortunately, the refinement of echocardiography and the creation of new diagnostic criteria have aided in the diagnosis of infective endocarditis in patients with SAB. These advancements have resulted in the development of an algorithm that combines clinical, microbiologic, and echocardiographic findings to stratify patients with SAB into different treatment regimens.
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PMID:Echocardiography for the Diagnosis of Staphylococcus aureus Infective Endocarditis. 1109 78

Staphylococcus aureus bacteraemia (SAB) originating from local infections can lead to severe secondary infections such as endocarditis. The protective effect of antibodies against secondary infections was studied in a rat model, where a local joint infection leads to bacteraemia and endocarditis on damaged aortic valves. In this study, immunizations with a truncated D2-domain of the S. aureus fibronectin-binding protein displayed on a cow-pea mosaic virus (CPMV-D) carrier induced protection against endocarditis (P < 0.05). Opsonization of S. aureus with antibodies raised against CPMV-D stimulated both neutrophil activity and macrophage phagocytosis in vitro. Furthermore, intravenous administration of these antibodies protected mice from weight loss due to SAB.
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PMID:Antibodies against a truncated Staphylococcus aureus fibronectin-binding protein protect against dissemination of infection in the rat. 1134 1

Background: Staphylococcus aureus bacteremia (SAB) may be complicated by endocarditis or metastatic infection without evidence of endocarditis (MIWE). The aim of this study was to identify risk factors for MIWE and endocarditis in patients with SAB. METHODS: We performed a retrospective chart review to compare characteristics of patients with uncomplicated SAB and patients whose SAB course was complicated by MIWE or endocarditis. We reviewed the charts of patients with SAB diagnosed in our department from 1992 to 1999 for S. aureus portal of entry, secondary foci of infection, underlying conditions, previous valvular defects, and foreign material. Endocarditis was defined according to the Duke criteria. Patients were classified as having MIWE when the diagnosis of endocarditis was not definite according to the Duke criteria and when there was evidence of at least one secondary metastatic infection other than endocarditis. RESULTS: Some 109 patients had 111 episodes of SAB. Sixty-three patients had no evidence of metastatic infection and constituted the control group. Twenty-seven patients developed at least one episode of MIWE. A community-acquired SAB (CI 95% OR: 1.4-12.3, P<0.02), two or fewer underlying conditions (CI 95% OR: 1.2-83, P<0.04), and a non-severe portal of entry (CI 95% OR: 1.2-20, P<0.03) were independently predictive for MIWE. The characteristics of 21 patients with endocarditis were compared with those of the control group. Only a previous valvular defect was significantly associated with endocarditis. CONCLUSION: A previous valvular defect seems to be an important factor for developing endocarditis during SAB. Risk factors for having MIWE may differ from those found for patients with endocarditis.
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PMID:Risk factors for metastatic infection in patients with Staphylococcus aureus bacteremia with and without endocarditis. 1291 37

The clinical presentation of patients with Staphylococcus aureus bacteraemia (SAB) varies from uncomplicated bacteraemia to a fulminant or deep-seated infection. To assess the clinical presentation and outcome and to detect possible flaws in management of these patients, a retrospective study was conducted including 75 adult patients with SAB admitted to a university hospital in The Netherlands between July 1999 and December 2000. In 26 of the 75 (35%) patients, SAB was complicated by a deep-seated infection. In 2 patients the diagnosis of infective endocarditis was missed. The overall mortality rate was 23%. In 10 (13%) patients death could be directly ascribed to SAB. In 3 of these 10 patients antimicrobial treatment had been inadequate. Relapse of infection occurred in 9 (12%) patients. Seven of these 9 patients were treated inadequately during the first infectious period. Two of the 9 patients died and another 2 suffered serious complications during relapse of infection. These findings stress the need for consultation of infectious disease specialists in management of patients with SAB and the urgent need for standardization and a guideline considering the approach of a patient with SAB. A proposal for such a guideline is presented in this manuscript.
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PMID:Management of patients with Staphylococcus aureus bacteraemia in a university hospital: a retrospective study. 1451 44

Our objectives were to determine the incidence of endocarditis in patients whose Staphylococcus aureus bacteremia was community-acquired, related to hemodialysis, or hospital-acquired; to assess clinical factors that would reliably distinguished between S. aureus bacteremia and S. aureus endocarditis; to assess the emergence of methicillin-resistant S. aureus (MRSA) as a cause of endocarditis; and to examine risk factors for mortality in patients with S. aureus endocarditis. We conducted a prospective observational study in 6 university teaching hospitals; we evaluated 505 consecutive patients with Staphylococcus aureus bacteremia. Thirteen percent of patients with S. aureus bacteremia were found to have endocarditis, including 21% with community-acquired S. aureus bacteremia, 5% with hospital-acquired bacteremia, and 12% on hemodialysis. Infection was due to MRSA in 31%. Factors predictive of endocarditis included underlying valvular heart disease, history of prior endocarditis, intravenous drug use, community acquisition of bacteremia, and an unrecognized source. Twelve patients with bacteremia had a prosthetic valve; 17% developed endocarditis. Unexpectedly, nonwhite race proved to be an independent risk factor for endocarditis by both univariate and multivariate analyses. Persistent bacteremia (positive blood cultures at day 3 of appropriate therapy) was identified as an independent risk factor for both endocarditis and mortality, a unique observation not reported in other prospective studies of S. aureus bacteremia. Patients with endocarditis due to MRSA were significantly more likely to have complicating renal insufficiency and to experience persistent bacteremia than those with endocarditis due to MSSA. The 30-day mortality was 31% among patients with endocarditis compared to 21% in patients who had bacteremia without endocarditis (p = 0.055). Risk factors for death due to endocarditis included severity of illness at onset of bacteremia (as measured by Apache III and Pitt bacteremia score), MRSA infection, and presence of atrioventricular block on electrocardiogram. Patients with S. aureus bacteremia who have community acquisition of infection, underlying valvular heart disease, intravenous drug use, unknown portal of entry, history of prior endocarditis, and possibly, nonwhite race should undergo echocardiography to screen for the presence of endocarditis. We recommend that blood cultures be repeated 3 days following initiation of antistaphylococcal antibiotic therapy in all patients with S. aureus bacteremia. Positive blood cultures at 3 days may prove to be a useful marker in promoting more aggressive management, including more potent antibiotic therapy and surgical resection of the valve in endocarditis cases. MRSA as the infecting organism should be added to the list of risk factors for consideration of valvular resection in cases of endocarditis.
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PMID:A prospective multicenter study of Staphylococcus aureus bacteremia: incidence of endocarditis, risk factors for mortality, and clinical impact of methicillin resistance. 1453 Jul 81

Staphylococcus aureus bacteremia is associated with substantial morbidity. Recurrence is common, but incidence and risk factors for recurrence are uncertain. The emergence of methicillin resistance and the ease of administering vancomycin, especially in patients who have renal insufficiency, have led to reliance on this drug with the assumption that it is as effective as beta-lactam antibiotics, an assumption that remains open to debate. We initiated a multicenter, prospective observational study in 6 university hospitals and enrolled 505 consecutive patients with S. aureus bacteremia. All patients were monitored for 6 months and patients with endocarditis were followed for 3 years. Recurrence was defined as return of S. aureus bacteremia after documentation of negative blood cultures and/or clinical improvement after completing a course of antistaphylococcal antibiotic therapy. All blood isolates taken from patients with recurrent bacteremia underwent pulsed-field gel electrophoresis testing. Recurrence was subclassified as reinfection (different pulsed-field gel electrophoresis patterns) or relapse (same pulsed-field gel electrophoresis pattern).Forty-two patients experienced 56 episodes of recurrence (79% were relapses and 21% were reinfection). Relapse occurred earlier than reinfection (median, 36 versus 99 d, p < 0.06). Risk factors for relapse of S. aureus bacteremia included valvular heart disease, cirrhosis of the liver, and deep-seated infection (including endocarditis). Nafcillin was superior to vancomycin in preventing bacteriologic failure (persistent bacteremia or relapse) for methicillin-susceptible S. aureus (MSSA) bacteremia. Failure to remove infected intravascular devices/catheters and vancomycin therapy were common factors in patients experiencing multiple (greater than 2) relapses. However, by multivariate analysis, only endocarditis and therapy with vancomycin (versus nafcillin) were significantly associated with relapse. Recurrences occurred in 9.4% of S. aureus bacteremias following antistaphylococcal therapy, and most were relapses. Duration of antistaphylococcal therapy was not associated with relapse, but type of antibiotic therapy was. Nafcillin was superior to vancomycin in efficacy in patients with MSSA bacteremia.
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PMID:Staphylococcus aureus bacteremia: recurrence and the impact of antibiotic treatment in a prospective multicenter study. 1453 Jul 82

This study reviews the outcome of patients with uncomplicated catheter-related Staphylococcus aureus bacteremia diagnosed in our hospital from January 1997 to December 1999 and treated with short-course antibiotic therapy. Our aim was to assess the effectiveness of this regimen for minimizing complications (relapses, endocarditis and metastatic foci). A total of 213 episodes of bacteremia were registered and 167 (78.4%) were nosocomial. Among these, 87 (52.1%) were catheter-related Staphylococcus aureus bacteremia and 20 were primary nosocomial bacteremia. Endocarditis was diagnosed during the acute episode in 7/107 of these patients (2 by persistent fever after catheter removal and 5 by metastatic foci; 3 of them also had cardiac risk factors) and confirmed with transesophageal echocardiography. Among the 84/87 catheter-related Staphylococcus aureus bacteremia and 16/20 primary nosocomial bacteremia patients who did not develop endocarditis, 31 patients died during the acute episode (16 due to sepsis despite initiation of antibiotic treatment and 15 due to the underlying disease) and five had osteoarticular foci. The remaining 64 episodes were considered to be uncomplicated bacteremia (no cardiac risk factors, persistent fever, metastatic foci, or clinical signs of endocarditis) and were treated with 10-14 days of high-dose antistaphylococcal antibiotics. Echocardiography was not mandatory in these patients. Of the 64 uncomplicated episodes, 62 were followed for at least 3 months and none relapsed or developed endocarditis. Even though some of the patients might have had subclinical endocarditis, short-course therapy with high doses of antistaphylococcal antibiotics was effective for treating uncomplicated catheter-related Staphylococcus aureus bacteremia. Transesophageal echocardiography may not be necessary in these cases.
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PMID:Management of catheter-related Staphylococcus aureus bacteremia: when may sonographic study be unnecessary? 1460 43

Staphylococcus aureus bacteremia (SAB) is still associated with a high mortality, and knowledge on risk factors and the clinical and the therapeutic aspects of SAB is still limited. This thesis focuses on the clinical aspects of SAB and its metastatic infections. In a study of all patients with bacteremia in Copenhagen County October 1992 through April 1993 (study I) we emphasized previous findings, that S. aureus is one of the most frequent pathogens in bacteremia, and in a case control study also in Copenhagen County 1994-95 (study II) we demonstrated, that not only an inserted central venous catheter and nasal S. aureus carriage but also hyponatremia and anemia are important risk factors for hospital-acquired SAB (study II). Studies on the treatment of SAB have pointed out, that the eradication of a primary is important, but there are only limited clinical studies dealing with antibiotic treatment. By logistic regression analysis, we were able to demonstrate that focus eradication is essential, but also that treatment with dicloxacillin 1 g x 4 or 2 g x 3 are superior to 1 g x 3 (studie III), indicating that the time for serum concentration above the Minimal Inhibitory Concentration (MIC) for the bacteria plays a role in the outcome of SAB treatment. S. aureus osteomyelitis secondary to SAB is frequently observed. No other countries, however, have a centralized registration, which make it possible to evaluate a large number of these patients. Since 1960, The Staphylococcal Laboratory, Statens Serum Institut in Copenhagen, has registrated selected clinical informations from nearly all patients with positive blood cultures of S. aureus. Based on this registration, we were able to show an increased number of S. aureus osteomyelitis among older patients and a decreased number of S. aureus osteomyelitis of femur and tibia among younger infants in the period 1980-90 (study IV). By reviewing the records of a large number of patients with vertebral S. aureus osteomyelitis, we could evaluate important aspects in the diagnosis and treatment of these patients (study V). We illustrated, that symptoms and laboratory findings were relatively unspecific, and CT-scanning or bone scintigraphy were absolutely necessary for the diagnosis (study V). The relatively high number of patients in the study allowed us to evaluate different treatment regimens, and we found, that treatment with penicillinase-stable penicillins four grams daily for at least eight weeks was necessary (study V). S. aureus meningitis is relatively uncommon and most often a neurosurgical infection based on the presence of a catheter. Meningitis secondary to SAB is relatively rare. The nationwide registration on Statens Serum Institut enabled us to study a large number of patients with special emphasis on clinical, outcome and treatment (study VI). We found, that these patients often were older people with chronic underlying diseases, the infection developed as a community-acquired infection, and the patients also had an unknown focus of infection. Furthermore, these patients often had other secondary manifestations such as endocarditis or osteomyelitis and an extremely high mortality (study VI). Finally, I believe that our studies will contribute to reduce the incidence of SAB and improve the diagnosis and treatment of SAB in the future.
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PMID:Staphylococcus aureus bacteremia. 1469 55


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