Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs... more Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs poses treatment challenges. Decisions regarding the need for operation are affected by concern for relapse of IE from ongoing injection drug use (IDU). The purpose of this study was to evaluate the effect of active IDU on outcomes after operation for IE. All patients with IE surgically treated at Cleveland Clinic from July 1, 2007 to July 1, 2012 were identified from the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Of 536 patients operated on for IE during the study period, 41 (8%) actively injected drugs. The primary outcome of the study was death or reoperation for IE. Patients who injected drugs had poorer survival free of reoperation, and the risk of events varied with time. In a multivariable Cox proportional hazards model, using time-dependent covariates, IDU was associated with a higher hazard of death or reoperation between 90 and...
ABSTRACT Background: In devising a treatment plan for patients with infective endocarditis (IE), ... more ABSTRACT Background: In devising a treatment plan for patients with infective endocarditis (IE), risk of mortality and complications with medical therapy alone have to be balanced against those with surgery. Decision-making can be improved by knowledge of outcomes in patients undergoing surgery for IE in experienced cardiac centers. Objective: To report contemporary outcomes in patients undergoing cardiac surgery for infectious endocarditis (IE) at Cleveland Clinic. Methods: From 1/2003 to 1/2008, 509 patients underwent surgical treatment of native valve (NVE) or prosthetic valve (PVE) IE. Data abstracted from prospective registries and medical records included demographics, microbiology, operative procedure, and surgical outcomes (Society for Thoracic Surgery National Database definitions). Results: 308 (61%) had NVE, and 201 (39%) had PVE, with or without other NVE. Mean age was 56 yrs and 70% were men. Isolated aortic valve (39%), isolated mitral valve (21%), and combined aortic and mitral (19%) procedures were most common. 21% had concomitant coronary artery bypass grafting. Most common pathogens were CN staphylococci (24%); S. aureus (23%), Streptococcus sp. (18%), and Enterococci (15%). Time from admission to cardiac surgery was 7.6 days. Postoperative stay was 15.3 days. Overall hospital mortality was 9.2%. Complications included reoperation for bleeding (7.5%), respiratory insufficiency (17%), renal failure (6.5%), and stroke (3.1%). Patients undergoing surgery for PVE vs. NVE were likely to have more preoperative heart failure (60% vs. 48%, P<.01), more postoperative renal failure (13% vs. 4.2%, P=.03), and higher hospital mortality (15% vs. 6.5%, P=.02). Conclusions: Approximately 100 patients undergo surgical treatment of IE at our institution annually. Patients with PVE have a significantly higher risk for post operative renal failure and hospital death when compared to patients with native valve IE.
Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs... more Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs poses treatment challenges. Decisions regarding the need for operation are affected by concern for relapse of IE from ongoing injection drug use (IDU). The purpose of this study was to evaluate the effect of active IDU on outcomes after operation for IE. All patients with IE surgically treated at Cleveland Clinic from July 1, 2007 to July 1, 2012 were identified from the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Of 536 patients operated on for IE during the study period, 41 (8%) actively injected drugs. The primary outcome of the study was death or reoperation for IE. Patients who injected drugs had poorer survival free of reoperation, and the risk of events varied with time. In a multivariable Cox proportional hazards model, using time-dependent covariates, IDU was associated with a higher hazard of death or reoperation between 90 and...
Hepatitis A can cause decompensation and death in patients with previous liver injury. The hepati... more Hepatitis A can cause decompensation and death in patients with previous liver injury. The hepatitis A vaccine is recommended for patients with chronic liver disease. The aim of this study was to screen, immunize, and measure the safety and antibody response of the hepatitis A vaccine in liver failure and liver transplant patients. This was a prospective immunization trial at a referral center for liver disease and liver transplantation. A total of 193 patients with severe chronic liver disease were screened and 24 patients were vaccinated. Sixteen end stage liver disease patients were compared with eight liver transplant patients. Hepatitis A vaccinations using 1440 ELISA units were given at 0 and 2 months. Serum hepatitis A antibody titers were measured after each vaccine dose. An antibody response > or = 33 mIU/ml was considered protective. Screening seropositive rate was 70 of 193 (36%) and 24 patients were available for vaccination. The median antibody titer was markedly low...
Alice Kim, MD, Marion J. Tuohy, MT(ASCP), Steve M. Gordon, MD, Gerri S. Hall, PhD, and Gary W. Pr... more Alice Kim, MD, Marion J. Tuohy, MT(ASCP), Steve M. Gordon, MD, Gerri S. Hall, PhD, and Gary W. Procop, MD, MS ... Mycobacteria cause a variety of human diseases that ... We present 3 scenarios of patients seen at The Cleve-land Clinic Foundation, in which molecular ...
To describe the investigation and interventions necessary to contain an outbreak of methicillin-r... more To describe the investigation and interventions necessary to contain an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in a neonatal intensive care unit (NICU). Retrospective case finding that involved prospective performance of surveillance cultures for detection of MRSA and molecular typing of MRSA by repetitive-sequence polymerase chain reaction (rep-PCR). Level III NICU in a tertiary care center. Three neonates in a NICU were identified with MRSA bloodstream infection on April 16, 2004. A point prevalence survey identified 6 additional colonized neonates (attack rate, 75% [9 of 12 neonates]). The outbreak strain was phenotypically unusual. Cohorting and mupirocin therapy were initiated for neonates who had acquired MRSA during the outbreak. Contact precautions were introduced in the NICU, and healthcare workers (HCWs) were retrained in cleaning and disinfection procedures and hand hygiene. Noncolonized neonates and newly admitted patien...
Testing excised valves in surgically treated infective endocarditis (IE) patients provides an opp... more Testing excised valves in surgically treated infective endocarditis (IE) patients provides an opportunity to identify the microbial etiology of IE. Microbial sequencing (universal bacterial, mycobacterial, or fungal polymerase chain reaction followed by DNA sequencing) of valves can identify microorganisms accurately, but the value it adds beyond information provided by blood and valve cultures has not been adequately explored. Three hundred fifty-six patients who underwent surgery for active IE from January 1, 2010, to January 1, 2013, were identified from our cardiovascular information registry and outpatient parenteral antibiotic therapy registry. Their records were reviewed to identify 174 patients whose valves were sent for sequencing. The microbial etiology of IE was defined using comprehensive clinical, pathologic, and microbiological criteria. Blood culture, valve culture, and valve sequencing were examined to determine how frequently they identified the definitive cause of IE. Of the 174 patients, 162 (93%) had acute inflammation on histopathologic examination of their valves. Valve sequencing was significantly more sensitive than valve culture in identifying the causative pathogen (90% versus 31%, p < 0.001), and yielded fewer false positive results (3% versus 33%, p <0.001). The pathogen would not have been identified in 25 patients (15%) had it not been for valve sequencing. All the value provided by sequencing was attributable to bacterial DNA sequencing; mycobacterial and fungal sequencing provided no additional information beyond that provided by blood culture, histopathology, and valve culture. Valve sequencing, not valve culture, should be considered the primary test for identifying bacteria in excised cardiac valves.
Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs... more Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs poses treatment challenges. Decisions regarding the need for operation are affected by concern for relapse of IE from ongoing injection drug use (IDU). The purpose of this study was to evaluate the effect of active IDU on outcomes after operation for IE. All patients with IE surgically treated at Cleveland Clinic from July 1, 2007 to July 1, 2012 were identified from the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Of 536 patients operated on for IE during the study period, 41 (8%) actively injected drugs. The primary outcome of the study was death or reoperation for IE. Patients who injected drugs had poorer survival free of reoperation, and the risk of events varied with time. In a multivariable Cox proportional hazards model, using time-dependent covariates, IDU was associated with a higher hazard of death or reoperation between 90 and...
ABSTRACT Background: In devising a treatment plan for patients with infective endocarditis (IE), ... more ABSTRACT Background: In devising a treatment plan for patients with infective endocarditis (IE), risk of mortality and complications with medical therapy alone have to be balanced against those with surgery. Decision-making can be improved by knowledge of outcomes in patients undergoing surgery for IE in experienced cardiac centers. Objective: To report contemporary outcomes in patients undergoing cardiac surgery for infectious endocarditis (IE) at Cleveland Clinic. Methods: From 1/2003 to 1/2008, 509 patients underwent surgical treatment of native valve (NVE) or prosthetic valve (PVE) IE. Data abstracted from prospective registries and medical records included demographics, microbiology, operative procedure, and surgical outcomes (Society for Thoracic Surgery National Database definitions). Results: 308 (61%) had NVE, and 201 (39%) had PVE, with or without other NVE. Mean age was 56 yrs and 70% were men. Isolated aortic valve (39%), isolated mitral valve (21%), and combined aortic and mitral (19%) procedures were most common. 21% had concomitant coronary artery bypass grafting. Most common pathogens were CN staphylococci (24%); S. aureus (23%), Streptococcus sp. (18%), and Enterococci (15%). Time from admission to cardiac surgery was 7.6 days. Postoperative stay was 15.3 days. Overall hospital mortality was 9.2%. Complications included reoperation for bleeding (7.5%), respiratory insufficiency (17%), renal failure (6.5%), and stroke (3.1%). Patients undergoing surgery for PVE vs. NVE were likely to have more preoperative heart failure (60% vs. 48%, P<.01), more postoperative renal failure (13% vs. 4.2%, P=.03), and higher hospital mortality (15% vs. 6.5%, P=.02). Conclusions: Approximately 100 patients undergo surgical treatment of IE at our institution annually. Patients with PVE have a significantly higher risk for post operative renal failure and hospital death when compared to patients with native valve IE.
Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs... more Infective endocarditis (IE) requiring surgical intervention in patients who actively inject drugs poses treatment challenges. Decisions regarding the need for operation are affected by concern for relapse of IE from ongoing injection drug use (IDU). The purpose of this study was to evaluate the effect of active IDU on outcomes after operation for IE. All patients with IE surgically treated at Cleveland Clinic from July 1, 2007 to July 1, 2012 were identified from the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Of 536 patients operated on for IE during the study period, 41 (8%) actively injected drugs. The primary outcome of the study was death or reoperation for IE. Patients who injected drugs had poorer survival free of reoperation, and the risk of events varied with time. In a multivariable Cox proportional hazards model, using time-dependent covariates, IDU was associated with a higher hazard of death or reoperation between 90 and...
Hepatitis A can cause decompensation and death in patients with previous liver injury. The hepati... more Hepatitis A can cause decompensation and death in patients with previous liver injury. The hepatitis A vaccine is recommended for patients with chronic liver disease. The aim of this study was to screen, immunize, and measure the safety and antibody response of the hepatitis A vaccine in liver failure and liver transplant patients. This was a prospective immunization trial at a referral center for liver disease and liver transplantation. A total of 193 patients with severe chronic liver disease were screened and 24 patients were vaccinated. Sixteen end stage liver disease patients were compared with eight liver transplant patients. Hepatitis A vaccinations using 1440 ELISA units were given at 0 and 2 months. Serum hepatitis A antibody titers were measured after each vaccine dose. An antibody response > or = 33 mIU/ml was considered protective. Screening seropositive rate was 70 of 193 (36%) and 24 patients were available for vaccination. The median antibody titer was markedly low...
Alice Kim, MD, Marion J. Tuohy, MT(ASCP), Steve M. Gordon, MD, Gerri S. Hall, PhD, and Gary W. Pr... more Alice Kim, MD, Marion J. Tuohy, MT(ASCP), Steve M. Gordon, MD, Gerri S. Hall, PhD, and Gary W. Procop, MD, MS ... Mycobacteria cause a variety of human diseases that ... We present 3 scenarios of patients seen at The Cleve-land Clinic Foundation, in which molecular ...
To describe the investigation and interventions necessary to contain an outbreak of methicillin-r... more To describe the investigation and interventions necessary to contain an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in a neonatal intensive care unit (NICU). Retrospective case finding that involved prospective performance of surveillance cultures for detection of MRSA and molecular typing of MRSA by repetitive-sequence polymerase chain reaction (rep-PCR). Level III NICU in a tertiary care center. Three neonates in a NICU were identified with MRSA bloodstream infection on April 16, 2004. A point prevalence survey identified 6 additional colonized neonates (attack rate, 75% [9 of 12 neonates]). The outbreak strain was phenotypically unusual. Cohorting and mupirocin therapy were initiated for neonates who had acquired MRSA during the outbreak. Contact precautions were introduced in the NICU, and healthcare workers (HCWs) were retrained in cleaning and disinfection procedures and hand hygiene. Noncolonized neonates and newly admitted patien...
Testing excised valves in surgically treated infective endocarditis (IE) patients provides an opp... more Testing excised valves in surgically treated infective endocarditis (IE) patients provides an opportunity to identify the microbial etiology of IE. Microbial sequencing (universal bacterial, mycobacterial, or fungal polymerase chain reaction followed by DNA sequencing) of valves can identify microorganisms accurately, but the value it adds beyond information provided by blood and valve cultures has not been adequately explored. Three hundred fifty-six patients who underwent surgery for active IE from January 1, 2010, to January 1, 2013, were identified from our cardiovascular information registry and outpatient parenteral antibiotic therapy registry. Their records were reviewed to identify 174 patients whose valves were sent for sequencing. The microbial etiology of IE was defined using comprehensive clinical, pathologic, and microbiological criteria. Blood culture, valve culture, and valve sequencing were examined to determine how frequently they identified the definitive cause of IE. Of the 174 patients, 162 (93%) had acute inflammation on histopathologic examination of their valves. Valve sequencing was significantly more sensitive than valve culture in identifying the causative pathogen (90% versus 31%, p < 0.001), and yielded fewer false positive results (3% versus 33%, p <0.001). The pathogen would not have been identified in 25 patients (15%) had it not been for valve sequencing. All the value provided by sequencing was attributable to bacterial DNA sequencing; mycobacterial and fungal sequencing provided no additional information beyond that provided by blood culture, histopathology, and valve culture. Valve sequencing, not valve culture, should be considered the primary test for identifying bacteria in excised cardiac valves.
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