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Diagnosis and treatment of infective endocarditis with emphasis on

Rasmus Vedby Rasmussen 

English summary

Background

Staphylococcus aureus and mortality, which reflects the difficulties associated with diagnosis and treatment of this condition. The increasing number of health-care related infections has led to an increasing incidence of (S. aureus) IE is a critical medical condition associated with a high morbidity S. aureus world. In order to improve outcome, studies within the field of diagnosis and treatment of aureus infections and S. aureus is now the most common cause of IE encountered in the industrializedS.IE is needed.

Objectives

The main objective of this thesis is to assess the value of echocardiographic screening for IE in patients with surgery on the outcome of IE with focus on S. aureus bacteremia (SAB), and to evaluate the impact of anticoagulation and cardiacS. aureus.

Methods

This thesis is based on 3 studies: I) a prospective multicenter observational study including 244 SAB patients who were all screened with echocardiography in order to determine the prevalence of IE. II) The association between anticoagulation and cerebral complications was evaluated in a prospective cohort study of 175 consecutive Database and Sahlgrenska Endocarditis Database. Data collection was based on standard case report forms and the databases were merged with respect to predefined variables of interest for this study. III) The impact of cardiac surgery on mortality was evaluated in 323 native valve IE patients ident ified in the East Danish Endocarditis Database. 40S. aureus IE patients from the East Danish Endocarditis.

Results

Of the 244 SAB patients included in paper I 53 patients (22%; 95% Confidence Interval (CI): 17- 27%) were diagnosed with definite IE. The prevalence of IE in high-risk patients with one or more predisposing condition or clinical evidence of IE were significantly higher compared to low-risk patients with no additional risk factors (38% vs. 5%; P<0.001) Major cerebral event was common in our were less likely to experience a major cerebral event upon admission 15% vs. 37%;P=0.009; adjusted Odds Ratio (OR) 0.27; 95% CI: 0.075-0.96; P=0.04. Cerebral haemorrhage was a rare complication diagnosed in only 3% of the patients. Cardiac surgery was associated with a survival benefit at 12-month when propensity score was applied in regression adjustment (Hazard Ratio (HR) 0.41, 95% CI: 0.25-0.68; p<0.001). Observed and predicted mortality was comparable when using the logistic euroSCORE 11% vs. 16% (NS). S. aureus IE population (40%) and patients receiving anticoagulation

Conclusion

SAB patients carry a high initial risk for the development of IE, which is known to be associated with a worse prognosis compared to uncomplicated SAB. The presenting symptoms and clinical findings associated with IE are often non-specific and echocardiography should always be considered in the initial evaluation of SAB patients. The potential harmful effect of anticoagulant therapy in  our data support the continuance of anticoagulation in S. aureus IE seems to be overestimated andS. aureus IE patients when indicated. Cardiac surgery is associated with a good prognosis when indicated, and surgery should only be withheld after thorough consideration. EuroSCORE is a valuable tool to identify high risk IE patients when surgery is considered.