OBJECTIVE: This study aimed to evaluate the effectiveness of dalbavancin as sequential therapy in patients with infective endocarditis (IE) due to gram positive bacteria (GPB) in a real-life heterogenous cohort with comorbid patients.
METHODS: A single center retrospective cohort study including all patients with definite IE treated with dalbavancin between January 2017 and February 2022 was developed. A 6-month follow-up was performed. The main outcomes were clinical cure rate, clinical and microbiological relapse, 6-month mortality, and adverse effects (AEs) rate.
RESULTS: The study included 61 IE episodes. The median age was 78.5 years (interquartile range [IQR] 63.2-85.2), 78.7% were male, with a median Charlson comorbidity index of 7 (IQR 4-9) points. Overall, 49.2% suffered native valve IE. The most common microorganism was Staphylococcus aureus (26.3%) followed by Enterococcus faecalis (21.3%). The median duration of initial antimicrobial therapy and dalbavancin therapy were 27 (IQR 20-34) and 14 days (IQR 14-28) respectively. The total reduction of hospitalization was 1090 days. The most frequent dosage was 1500mg of dalbavancin every 14 days (96.7%). An AE was detected in 8.2% of patients, only one (1.6%) was attributed to dalbavancin (infusion reaction). Clinical cure was achieved in 86.9% of patients. One patient (1.6%) with Enterococcus faecalis IE suffered relapse. The 6-month mortality was 11.5%, with only one IE-related death (1.6%).
CONCLUSIONS: This study shows a high efficacy of dalbavancin in a heterogeneous real-world cohort of IE patients, with an excellent safety profile. Dalbavancin allowed a substantial reduction of in-hospital length of stay.

BACKGROUND: Dalbavancin (DBV), a novel lipoglycopeptide with activity against Gram-positive bacterial infections, is approved for the treatment of acute bacterial skin and skin structure infections (ABSSSIs). It has linear dose-related pharmacokinetics allowing a prolonged interval between doses. It would be a good option for the treatment of patients with Gram-positive cardiovascular infections.
METHODS: Retrospective analysis of patients with cardiovascular infection (infective endocarditis, bacteremia, implantable electronic device infection) treated with DBV at Hospital Clínico San Carlos (Madrid) for 7 years (2016-2022). Patients were divided in two study groups: 1) Infective endocarditis (IE), 2) Bacteremia. Epidemiological, clinical, microbiological and therapeutic data were analyzed.
RESULTS: A total of 25 patients were treated with DBV for cardiovascular infection. IE was the most common indication (68%), followed by bacteremia (32%) with male predominance in both groups (64% vs 62%) and median age of 67,7 and 57,5 years, respectively. 100% of blood cultures were positive to Gram-positive microorganisms (Staphylococcus spp., Streptococcus spp. or Enterococcus spp.) in both study groups. Previously to DBV, all patients received other antibiotic therapy, both in the group of IE (median: 80 days) as in bacteremia (14,8 days). The main reason for the administration of DBV was to continue intravenous antimicrobial therapy outside the hospital in both the EI group (n = 15) and the bacteremia group (n = 8). DBV was used as consolidation therapy in a once- or twice-weekly regimen. Microbiological and clinical successes were reached in 84% of cases (n = 21), 76,4% in IE group and 100% in bacteremia group. No patient documented adverse effects during long-term dalbavancin treatment.
CONCLUSIONS: DBV is an effective and safety treatment as consolidation antibiotic therapy in IE and bacteremia produced by Gram-positive microorganisms.

OBJECTIVE: Diffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE.
METHODS: From 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis.
RESULTS: The prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy.
CONCLUSIONS: Valvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

OBJECTIVE: Our aim was to describe the contemporary epidemiological profile of infective endocarditis (IE) in Spain, and to evaluate variations in IE incidence, characteristics, and outcomes among the different Spanish regions (autonomous communities [AC]).
METHODS: We conducted a retrospective, population-based study, using data obtained from national in-patient hospital activity of all patients discharged with a diagnosis of IE from hospitals included in the Spanish National Health System, from January 2016 to December 2019. Differences in the IE profile between the 17 Spanish AC were analyzed.
RESULTS: A total of 9008 hospitalization episodes were identified during the study period. Standardized incidence of IE was 5.77 (95%CI, 5.12-6.41) cases per 100 000 population. Regarding predisposing conditions, 26.8% of episodes occurred in prosthetic valve carriers, 36.8% had some kind of valve heart disease, and 10.6% had a cardiac implantable electronic device. Significant differences were found between AC in terms of incidence, predisposing conditions, and microbiological profile. Cardiac surgery was performed in 19.3% of episodes in the total cohort, and in 33.4% of the episodes treated in high-volume referral centers, with wide variations among AC. Overall in-hospital mortality was 27.2%. Risk-adjusted mortality rates also varied significantly among regions.
CONCLUSIONS: We found wide heterogeneity among Spanish AC in terms of incidence rates and the clinical and microbiological characteristics of IE episodes. The proportion of patients undergoing surgery was low and in-hospital mortality rates were high, with wide differences among regions. The development of regional networks with referral centers for IE could facilitate early surgery and improve outcomes.

BACKGROUND: Fungal endocarditis is a low-frequency disease with a challenging diagnosis, as it can be mistaken with bacterial endocarditis. Fungal endocarditis causes higher mortality rates in immunocompromised patients. In the clinical practice, the endocarditis caused by fungi represents up to 10% of all infectious endocarditis cases and has a mortality rate of nearly 50%.
METHODS: Here we present the case of a 53-year-old woman under corticosteroid therapy with a history of rheumatic heart disease, aortic valve replacement, and rheumatoid arthritis, who presented with fungal endocarditis caused by Candida albicans. Even though the patient received 3 years of antifungal prophylaxis with fluconazole, had valve replacement surgery, and received intensive care, the patient finally worsened and died.
CONCLUSIONS: Comorbidities and corticosteroid therapy predisposed the patient to acquire fungal endocarditis. This case highlights the importance of implementing procedures for the isolation and identification of fungi, and for carrying out antifungal-susceptibility testing, as well as establishing surveillance programs to identify infection-causing species and drug resistance patterns in hospitals. Moreover, designing and upgrading the algorithm for infectious endocarditis is the key to future improvements in diagnosis.

OBJECTIVE: To describe clinical, microbiological and echocardiographic aspects of endocarditis in a specific group of patients without intracardiac devices or underlying structural heart disease.
METHODS: Retrospective study, clinical records and echocardiographic reports were reviewed during the period 1997 to 2020. Duke\'s modified criteria were applied. Statistical analysis: univariate expressed in frequencies, using measures of dispersion and central tendency.
RESULTS: 30,000 echocardiographic reports were reviewed, only 1350 had infectious endocarditis as a reason for sending, of which 248 cases were selected. The mean age was 48.1 ± 16.7 years. 140 men (56%) and 108 women (44%). The most frequent echocardiographic sign was vegetation, in 278 (93.60%), and most common location was mitral (35.55%), with a higher number of cases in the right ventricle than expected. The most common systemic disease was kidney disease, in 135 (41.08%). A case of Streptococcus thoraltensis not previously reported in Mexico was identified.
CONCLUSIONS: The presence of infectious endocarditis has increased due to invasive in-hospital and drug procedures. Due to their complexity, multidisciplinary teams are indispensable.
OBJECTIVE: Describir aspectos clínicos, microbiológicos y ecocardiográficos de endocarditis en un grupo específico de pacientes sin dispositivos intracardiacos ni cardiopatía estructural subyacente.
UNASSIGNED: Estudio retrospectivo en el que se revisaron expedientes clínicos y reportes ecocardiográficos durante el periodo de 1997 a 2020. Se aplicaron los criterios modificados de Duke. Se describió la muestra por edad, sexo, enfermedad sistémica, vegetaciones y agente microbiológico. Se excluyeron pacientes con cardiopatía estructural o Libman-Sacks. Análisis estadístico: univariado expresado en frecuencias, utilizando medidas de dispersión y tendencia central.
RESULTS: Se revisaron 30,000 reportes ecocardiográficos, de los cuales solo 1350 tenían como motivo de envío endocarditis infecciosa, y de estos se seleccionaron 248 casos. La edad promedio fue de 48.1 ± 16.7 años. Hubo 140 hombres (56%) y 108 mujeres (44%). El signo ecocardiográfico más frecuente fue la vegetación, en 278 (93.60%), y la ubicación más común fue mitral (35.55%), con un número mayor de casos en el ventrículo derecho de lo esperado. La enfermedad sistémica más común fue la enfermedad renal, en 135 (41.08%). Se identificó un caso de Streptococcus thoraltensis no reportado previamente en México.
CONCLUSIONS: La presencia de endocarditis infecciosa ha aumentado debido a procedimientos invasivos intrahospitalarios y fármacos. Por su complejidad, los equipos multidisciplinarios son indispensables.

BACKGROUND: Neurological complications are the most frequent type of extracardiac complications of infective endocarditis (IE), and can be the initial manifestation. The objectives of this study were to determine the prevalence of neurological complications in patients with IE and to evaluate whether initial presentation with neurological symptoms causes a diagnostic delay.
METHODS: We conducted a retrospective observational study of patients with IE admitted to a tertiary hospital between 2003 and 2020.
RESULTS: The study included 222 patients with IE (67% men; mean [SD] age, 66.4 [14.2] years). Neurological complications occurred in 21.2% of patients, with ischaemic stroke (74.5%) and intracerebral haemorrhage (23.4%) being the most frequent. No differences in diagnostic delay were found between the group of patients in whom the disease manifested with neurological complications and the rest of the patients (4.4 vs 4.5; P = .76).
CONCLUSIONS: A total of 21.2% of patients with IE presented neurological complications, with ischaemic stroke being the most frequent. Neurological symptoms as the initial manifestation of IE did not lead to a delay in diagnosis.

Streptococcus bovis/equinus complex (SBEC) is a major cause of infective endocarditis (IE), although its incidence varies greatly depending on the geographical area. The characteristics of IE caused by Streptococcus gallolyticus susp. gallolyticus are well known; there are hardly any descriptions of IE caused by other species or biotypes.
Retrospective cohort study, from 1990 to 2019, of all SBEC IE in adults in three Spanish hospitals, Lugo (LH), Barcelona (BH) and Ferrol (FH) where the population is mainly rural, urban and mixed, respectively. The incidence of IE was analyzed in 3 areas. Clinical characteristics of IE (277 cases, 258 biotyped) were compared according to SBEC species and biotypes.
There are significant differences between the incidence of SBEC IE in HL (27.9/106) vs. HF and HB (8.8 and 7,1, respectively, p<0.001). We found significant differences (SbI vs. SbII) in mean age (68.5 vs. 73 years; p<0.01), duration of symptoms before diagnosis (46.9±46.5 vs. 30.4±40.9 days; p<0.01), presence of comorbidities: 39.1% (78) vs. 54.2% (32; p<0.04), predisposing heart illness:62.3% (124) vs. 81.3% (48; p<0.006), particularly, prosthetic or intravascular devices IE: 24.6% (49) vs. 52.4% (31; p<0.001), bi-valve involvement:23.6% (47) vs. 11.8% (7; p<0.05) and heart failure: 24.6% (49) vs. 38.9% (23; p<0.03). There were no significant differences in embolic events, need for surgery or mortality. The association with CRC was high in both groups: 77.7% vs. 66.6%.
IE due to SBEC has geographical variations in incidence and different clinical characteristics among biotypes. The association with CRC was high.

OBJECTIVE: Association between S. gallolyticus infective endocarditis (IE) and malignant lesions of the gastrointestinal tract is well described. We hypothesize that other enteropathogenic microorganisms, such as S. viridans and E. faecalis are also related with colorectal pathology. Our aim is to determine the frequency of focal colorectal FDG deposits, suggestive of tumoral lesions and their correlation with colorectal pathology, in patients with infection caused by different commensal microorganisms of the gastrointestinal tract.
METHODS: We retrospectively examined 61 patients diagnosed with bacteremia (BSI) and IE (possible or definite) according to Duke\'s criteria, caused by enteropathogenic microorganisms, who underwent a full-body [18F]FDG-PET/CT in our institution. We looked for colorrectal FDG deposits and morphological lesions. All IE patients underwent a complete colonoscopy and the histological results were classified into four groups: malignant lesion, premalignant lesion, benign lesion and no lesion. We evaluated the correlation between the findings of the [18F]FDG-PET/CT with the histopathological diagnosis and the involved microorganism.
RESULTS: PET/CT detected 20 colorectal FDG deposits (32.79%-OR: 47.28), 2 within bacteriemic patients (16.7%) confirmed as malignant and premalignant lesions and 18 in IE group (36.6%), 17 of them corresponding to colorrectal pathology: 11 malignant, 5 premalignant and 1 benign lesions. In the IE subgroup, the colonoscopy detected colorectal lesions in 51.02% of the patients: 11malignant, 8premalignant and 6benign. We found a higher incidence of colorectal FDG deposits in Streptococcus spp. subgroup. Regarding the anatomopathological colonic findings there was a predominance of patients affected by S. viridans, followed by E. faecalis and S. gallolyticus.
CONCLUSIONS: Patients studied by PET/CT for systemic infection, especially IE, caused by S. viridans or E. faecalis, in addition to S. gallolyticus, show a greater probability of presenting incidental colorectal FDG deposits, mostly corresponding to malignant or pre-malignant lesions. Therefore, it is necessary to carry out an exhaustive search of possible colorectal foci in these exams.

OBJECTIVE: Staphylococcus aureus is a well-known biofilm-producing pathogen that is capable of causing chronic infections owing to its ability to resist antibiotic treatment and obstruct the immune response. However, the possible association between high biofilm production and infective endocarditis (IE) has not been assessed. Our objective was to compare production of biofilm by S. aureus strains isolated from patients with bacteremia and IE, catheter-related bloodstream infection (C-RBSI), or non-device associated bacteremia.
METHODS: We isolated 260 S. aureus strains from the blood of patients with bacteremia who were diagnosed during hospital admission between 2012 and 2015. Patients were divided into 3 groups according to whether they had IE, C-RBSI, or non-device associated bacteremia. Biofilm production was measured in terms of biomass and metabolic activity using the crystal violet and XTT assays, respectively. High biomass and metabolic activity rates (based on tertile ranks classification) were compared between the 3 groups.
RESULTS: The high biomass and metabolic activity rates of each group were 41.9% and 37.2% for IE, 32.5% and 35.0%, for C-RBSI, and 29.0% and 33.3% for non-device associated bacteremia (p=0.325 and p=0.885, respectively).
CONCLUSIONS: High biomass and metabolic activity levels for S. aureus isolates from IE were similar to those of S. aureus isolates from C-RBSI or non-device associated bacteremia.