Publications by authors named "Walter R Wilson"

95 Publications

Rapid Appraisal System for COVID-19 Medical Information.

Mayo Clin Proc 2020 09 22;95(9S):S26-S28. Epub 2020 Jun 22.

Division of Infectious Diseases, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1016/j.mayocp.2020.05.042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306744PMC
September 2020

Augmented curation of clinical notes from a massive EHR system reveals symptoms of impending COVID-19 diagnosis.

Elife 2020 07 7;9. Epub 2020 Jul 7.

nference, Cambridge, United States.

Understanding temporal dynamics of COVID-19 symptoms could provide fine-grained resolution to guide clinical decision-making. Here, we use deep neural networks over an institution-wide platform for the augmented curation of clinical notes from 77,167 patients subjected to COVID-19 PCR testing. By contrasting Electronic Health Record (EHR)-derived symptoms of COVID-19-positive (COVID; n = 2,317) versus COVID-19-negative (COVID; n = 74,850) patients for the week preceding the PCR testing date, we identify anosmia/dysgeusia (27.1-fold), fever/chills (2.6-fold), respiratory difficulty (2.2-fold), cough (2.2-fold), myalgia/arthralgia (2-fold), and diarrhea (1.4-fold) as significantly amplified in COVID over COVID patients. The combination of cough and fever/chills has 4.2-fold amplification in COVID patients during the week prior to PCR testing, in addition to anosmia/dysgeusia, constitutes the earliest EHR-derived signature of COVID-19. This study introduces an platform for the real-time synthesis of institutional biomedical knowledge. The platform holds tremendous potential for scaling up curation throughput, thus enabling EHR-powered early disease diagnosis.
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http://dx.doi.org/10.7554/eLife.58227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410498PMC
July 2020

Discriminative Ability and Reliability of Transesophageal Echocardiography in Characterizing Cases of Cardiac Device-Lead Vegetations versus Non-Infectious Echodensities.

Clin Infect Dis 2020 Jun 13. Epub 2020 Jun 13.

Division of Infectious Diseases, Rochester MN.

Background: Approximately one third of cases of cardiovascular implantable electronic device (CIED) infection present as CIED lead infection. The precise transesophageal echocardiographic (TEE) definition and characterization of "vegetation" associated with CIED lead infection remain unclear.

Methods: We identified a sample of 25 consecutive cases of CIED lead infection managed at our institution between January 2010 and December 2017. Cases of CIED lead infection were classified using standardized definitions. Similarly, a sample of 25 non-infected patients who underwent TEE that showed a defined lead echodensity during the study period were included as a control group. TEEs were reviewed by two independent echocardiologists who were blinded to all linked patient demographic, clinical and microbiological information. Reported echocardiographic variables of the infected versus non-infected cases were compared, and the overall diagnostic performance analyzed.

Results: Descriptions of lead echodensities were variable and there were no significant differences in median echodensity diameter or mobility between infected versus non-infected groups. Among infected cases, blinded echocardiogram reports by either reviewer correctly made a prediction of infection in 6/25 (24%). Inter-echocardiologist agreement was of 68%. Sensitivity of blinded TEEs ranged from 31.5% to 37.5%.

Conclusion: Infectious versus non-infectious lead echodensities could not be reliably distinguished on the basis of size, mobility, and general shape descriptors obtained from a retrospective blinded TEE examination without knowledge of clinical and microbiological parameters. Therefore, a reanalysis of criteria used to support a diagnosis of CIED lead infection may be warranted.
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http://dx.doi.org/10.1093/cid/ciaa472DOI Listing
June 2020

Repeat transesophageal echocardiography in infective endocarditis: An analysis of contemporary utilization.

Echocardiography 2020 06 16;37(6):891-899. Epub 2020 May 16.

Department of Medicine, Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN, USA.

Background: Current guidelines from the American Heart Association (AHA) recommend repeating transesophageal echocardiography (TEE) in three to five days if there is high suspicion of IE despite an initial TEE that was negative. This recommendation, however, is based on limited published data.

Objectives: This investigation attempts to identify specific factors that prompted repeat TEE and evaluate the yield of IE-related findings demonstrated by repeat TEE as compared to initial or prior TEE.

Methods: A retrospective cohort who had at least one repeat TEE during an index hospitalization or initial course of antimicrobial therapy for IE between January 2014 and September 2018. We assessed the impact of repeat TEE on IE diagnosis and patient management and included a comparative analysis of patients with initial TEE only.

Results: Overall, 59 (44.7%) of 132 IE patients underwent repeat TEE. In a comparative analysis that involved patients who had undergone an initial TEE only versus those who had repeat TEE, male gender (P = .029) and presence of a prosthetic valve or annuloplasty ring (P = .017) were significantly associated with repeat TEE. Importantly, 8 (17.4%) of repeat TEE were critical for IE diagnosis, 8 (17.4%) impacted antimicrobial management, and 11 (23.9%) supported cardiovascular surgical intervention.

Conclusions: From a population-based cohort of incident IE cases, repeat TEE was more frequently (44.7%) done in patients with suspect or proven IE and associated complications than anticipated. Repeat TEE remains pivotal in a contemporary practice that involves critical aspects of IE diagnosis and management.
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http://dx.doi.org/10.1111/echo.14676DOI Listing
June 2020

Migratory Polyarthralgias and Skin Rash: Rat Bite Fever with a Positive Anti-Cyclic Citrullinated Peptide.

Mayo Clin Proc Innov Qual Outcomes 2020 Apr 9;4(2):223-227. Epub 2020 Mar 9.

Division of Infectious Diseases, Mayo Clinic, Rochester, MN.

Rat bite fever is a rare, underdiagnosed disease caused by in the United States, and is typically characterized by leukocytosis, elevated C-reactive protein, migratory polyarthralgias, and pustular skin rash. Rat bite fever is frequently misdiagnosed as either a viral illness or a rheumatologic disease and carries a high mortality risk if untreated. We report the first case of rat bite fever associated with positive anti-cyclic citrullinated peptide. The patient initially presented with low back pain and developed a pustular rash as well as severe asymmetric polyarthralgias. Blood cultures turned positive for and the patient completed a 4-week course of antibiotics for presumed septic arthritis.
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http://dx.doi.org/10.1016/j.mayocpiqo.2019.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140017PMC
April 2020

End-of-Therapy Echocardiography May Not Be Needed in All in Patients With Endocarditis.

Open Forum Infect Dis 2020 Mar 28;7(3):ofaa069. Epub 2020 Feb 28.

Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Background: The American Heart Association (AHA) guidelines for infective endocarditis (IE) management recommend end-of-therapy (EOT) echocardiography (ETE) to "establish a new baseline" and based on "expert opinion."

Methods: Medical records of IE patients treated between January 2005 and December 2011 were reviewed. Utilization of ETE and cumulative incidence of re-treatment with antimicrobials or cardiovascular surgery (re-Rx/CVS) within 1 year after EOT were evaluated.

Results: A total of 243 patients completed clinical follow-up at EOT and 170 at 1 year after EOT. One hundred seventy-seven of 243 (72.8%) underwent ETE, the majority (51.4%) transthoracic echocardiography. One hundred thirty-three of 177 (75.1%) were without new/worsened signs or symptoms (new/w-SSx). One hundred forty-one of 177 (79.7%) overall and 117/133 (87.9%) patients without new/w-SSx had no new ETE findings as compared with initial echocardiography. Among 36/177 (20.3%) with new ETE findings, 20/36 (55.6%) had new/w-SSx; ETE findings were more likely in patients with new/w-SSx (39.2% vs 8.3%;  < 0.001) at EOT. Patients were at increased risk of re-Rx/CVS with either new ETE findings (hazard ratio [HR], 25.86; 95% confidence interval [CI], 7.64-87.56;  < .001) or new/w-SSx (HR, 5.35; 95% CI, 2.87-9.95;  < .001). The highest risk of re-Rx/CVS was in patients with both new/w-SSx and new ETE findings (HR, 45.94; 95% CI, 19.07-110.71). Conversely, only 7/187 (3.4%) patients without new/w-SSx who had an ETE required re-Rx/CVS.

Conclusions: The majority of patients without new/w-SSx at EOT will not have new ETE findings or need re-Rx/CVS within 1 year after EOT. EOT new/w-SSx is associated with new ETE findings and predicts the need for re-Rx/CVS. Further study is needed to determine whether patients without new/w-SSx need ETE.
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http://dx.doi.org/10.1093/ofid/ofaa069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080304PMC
March 2020

Predictors of Bloodstream Infection in Patients Presenting With Cardiovascular Implantable Electronic Device Pocket Infection.

Open Forum Infect Dis 2019 Apr 21;6(4):ofz084. Epub 2019 Feb 21.

Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester Minnesota.

Background: Generator pocket infection is the most frequent presentation of cardiovascular implantable electronic device (CIED) infection. We aim to identify predictors of underlying bloodstream infection (BSI) in patients presenting with CIED pocket infection.

Methods: We retrospectively reviewed all adults with CIED pocket infection cared for at our institution from January 2005 through January 2016. The CIED pocket infection cases were then subclassified as with or without associated BSI. Variables with values <.05 at univariate analysis were included in a multivariable model to identify independent predictors of underlying BSI.

Results: We screened 429 cases of CIED infection, and 95 met the inclusion criteria. Of these, 68 cases (71.6%) were categorized as non-BSI and 27 (28.4%) as BSI. There were no statistically significant differences in patient comorbid conditions or device characteristics between the 2 groups. In multivariable analysis, the presence of systemic inflammatory response syndrome criteria (tachycardia, tachypnea, fever or hypothermia, and leukocytosis or leukopenia) and hypotension were independent predictors of underlying BSI in patients presenting with CIED pocket infection. Overall, patients in the non-BSI group who did not receive pre-extraction antibiotics had a higher frequency of positive intraoperative pocket/device cultures than those with pre-extraction antibiotic exposure (79.4% vs 58.6%; = .06).

Conclusions: Patients with CIED pocket infection who meet systemic inflammatory response syndrome criteria and/or are hypotensive at admission are more likely to have underlying BSI and should be started on empiric antibiotics after blood cultures are obtained. If these features are absent, it may be reasonable to withhold empiric antibiotics to optimize yield of pocket/device cultures during extraction.
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http://dx.doi.org/10.1093/ofid/ofz084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6456888PMC
April 2019

Clinical Presentation, Management, and Outcomes of Cardiovascular Implantable Electronic Device Infections Due to Gram-Negative Versus Gram-Positive Bacteria.

Mayo Clin Proc 2019 07 17;94(7):1268-1277. Epub 2019 Mar 17.

Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN. Electronic address:

Objective: To describe and compare the clinical presentation, management, and outcomes of cardiovascular implantable electronic device (CIED) infections due to gram-negative bacteria (GNB) and CIED infections due to gram-positive bacteria (GPB).

Patients And Methods: We retrospectively reviewed all CIED infection cases at Mayo Clinic from January 1, 1992, through December 31, 2015. Cases were classified based on positive microbiology data from extracted devices or blood cultures.

Results: Of the 623 CIED infections during the study period, 31 (5.0%) were caused by GNB and 323 (51.8%) by GPB. Patients in the GNB group were more likely to present with local inflammatory findings at the pocket site (90.3% vs 72.4%; P=.03). All patients with bacteremia due to GNB had concomitant pocket infection compared with those with GPB (100% vs 33.9%; P=.002). After extraction, 41.9% of patients in the GNB group were managed with oral antibiotics vs 2.4% in the GPB group (P<.001). There were no statistically significant differences in infection relapse/recurrence or 1-year survival rates between the 2 groups.

Conclusion: Compared with CIED infections caused by GPB, those due to GNB are more likely to present with pocket infection. Device-related GNB bacteremia almost always originates from the generator pocket. After extraction, oral antibiotic drug therapy may be a reasonable option in select cases of pocket infections due to GNB. No difference in outcomes was observed between the 2 groups.
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http://dx.doi.org/10.1016/j.mayocp.2018.11.029DOI Listing
July 2019

Infective endocarditis following transcatheter aortic valve replacement: Diagnostic yield of echocardiography and associated echo-Doppler findings.

Int J Cardiol 2018 Nov;271:392-395

Department of Cardiovascular Medicine, Mayo Clinic, MN, United States.

Background: Studies have suggested the diagnostic yield of echocardiography to be lower in prosthetic valve endocarditis (PVE) after transcatheter aortic valve replacement (TAVR) than reported in surgically-implanted valves but data are limited.

Methods: We reviewed transthoracic (TTE) and transesophageal (TEE) echo-Doppler findings in 17 patients with PVE (13 definite and 4 possible cases according to modified Duke criteria) after TAVR at Mayo Clinic, Rochester, MN between 2007 and 2016.

Results: Median age was 81 years [56; 91] and 5 patients (29%) were female. Median Society of Thoracic Surgery predicted risk of mortality was 8.8%. PVE occurred 197 days [27; 923] after TAVR. Enterococcus faecalis was the most commonly encountered organism (29%). All patients had TEE performed at the time of PVE; TTE was performed in 11 patients. TEE was diagnostic for PVE in 47% of cases and TTE in 18%. TEE was diagnostic in 62% of patients if only definite PVE cases are included. Two patients showed prosthetic obstruction at the time of PVE; obstruction improved with antibiotic therapy in the surviving patient.

Conclusion: Standard echocardiography techniques had limited diagnostic performance in patients with TAVR-related PVE. PVE can present as features of TAVR obstruction, thus PVE should also be considered in patients presenting with worsening prosthetic obstruction.
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http://dx.doi.org/10.1016/j.ijcard.2018.03.124DOI Listing
November 2018

Comparison of Dual β-Lactam therapy to penicillin-aminoglycoside combination in treatment of Enterococcus faecalis infective endocarditis.

J Infect 2018 11 30;77(5):398-404. Epub 2018 Jun 30.

Division of Infectious Diseases, MayoClinic, Rochester, MN, USA; Department of Cardiovascular Diseases, MayoClinic, Rochester, MN, USA.

Background: Dual β-lactam therapy and a penicillin-aminoglycoside combination are first line regimens in the treatment of penicillin-susceptible Enterococcus faecalis infective endocarditis (EFIE). Our aim was to compare ampicillin plus ceftriaxone (A+C) to ampicillin plus gentamicin (A+G) in the treatment of EFIE.

Methods: This was a retrospective cohort study of adults (≥18 years) patients diagnosed with EFIE at Mayo Clinic campuses in Rochester, Minnesota, and Phoenix, Arizona and treated with either A+C or A+G. Main outcome measurements were 1 year mortality, nephrotoxicity, and EFIE relapse rates.

Results: Eighty-five cases of EFIE were included in this investigation. The majority (n=67, 79%) of patients received A+G while 18 (21%) patients received A+C as initial treatment. On admission, patients who received A+C had a higher Charlson Comorbidity Index (median [IQR], 4 [3, 4 vs. 2 [1, 4]; P=.008) and a higher baseline serum creatinine (median [IQR], 1.2 [0.9, 1.6] vs. 0.9 [0.8, 1.2] mg/dL, P=.020). The 1 year mortality rates were similar for both treatment groups, 17% vs. 17%, P=.982. Each group had 1 case of relapsing EFIE. Patients who received A+G had worse kidney function outcome demonstrated by a greater increase in serum creatinine at end of therapy (median [IQR] difference, +0.4 [0.2, 0.8] vs. -0.2 [-0.3, 0.1] mg/dL, P≤.001).

Conclusion: A+C appears to be a safe and efficacious regimen in the treatment of EFIE. Patients treated with A+C had lower rates of nephrotoxicity and no differences in relapse rate and 1-year mortality as compared to that of the A+G group.
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http://dx.doi.org/10.1016/j.jinf.2018.06.013DOI Listing
November 2018

Diagnostic evaluation and management of culture-negative cardiovascular implantable electronic device infections.

Pacing Clin Electrophysiol 2018 May 31. Epub 2018 May 31.

Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Background: Culture-negative (CN) cardiovascular implantable electronic device (CIED) infections represent a significant management challenge for clinicians with no specific guidelines addressing this subgroup of patients. The aim of the current investigation is to report our institutional experience of CN CIED infections and propose a systematic approach to diagnostic evaluation and management of these complicated cases based on our observations.

Methods: We retrospectively screened all CIED infection cases at Mayo Clinic from 2005 through 2017. Using standardized criteria to define significant microbial growth, all patients with positive blood or pocket/device cultures were excluded.

Results: A total of 835 cases of CIED infection were screened, and of these, 47 (6%) met CN-CIED infection criteria. Majority of patients (77%) in this cohort had received antimicrobial therapy prior to device cultures with a median duration of 8 days. The most common presentation was device pocket infection (81%). All patients underwent device removal. Route of antibiotics was switched from oral to parenteral and spectrum of activity expanded from initial therapy in 23% of patients despite negative cultures. Majority of patients (80%) were dismissed on parenteral therapy. Adverse events attributed to intravenous antibiotic therapy were documented in 63% of the cases. No recurrence was reported and 6-month survival was 94.8%.

Conclusions: Pocket and device cultures in suspected CIED infections may be negative due to preextraction oral antibiotics. However, frequently these patients are managed with broad-spectrum parenteral therapy postextraction.
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http://dx.doi.org/10.1111/pace.13397DOI Listing
May 2018

Utility of cardiac computed tomography scanning in the diagnosis and pre-operative evaluation of patients with infective endocarditis.

Int J Cardiovasc Imaging 2018 Jul 15;34(7):1155-1163. Epub 2018 Feb 15.

Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA.

Transesophageal echocardiography (TEE) is the gold standard imaging study used in the diagnosis of infective endocarditis (IE). Computed tomography angiography (CTA) has undergone rapid advancement as a cardiac imaging technique and has previously shown promise in small non-randomized studies for evaluation of IE. We hypothesized that cardiac CTA would perform similarly to TEE in the detection of endocarditic lesions and that there would be no difference in clinical outcomes whether the coronary arteries were evaluated by CTA or invasive coronary angiography (ICA). 255 adults who underwent surgery for IE at the Mayo Clinic Rochester between January 1, 2006 and June 1, 2014 were identified retrospectively. 251 patients underwent TEE and 34 patients underwent cardiac CTA. TEE had statistically higher detection of vegetations (95.6 vs. 70.0%, p < 0.0001) and leaflet perforations (81.3 vs. 42.9%, p = 0.02) as compared to cardiac CTA. For detection of abscess/pseudoaneurysm TEE had a similar sensitivity to cardiac CTA (90.5 vs. 78.4%, p = 0.21). There was no significant difference in peri-operative outcomes whether coronary arteries were evaluated by CTA or ICA. The greatest advantage of cardiac CT in the setting of IE is its ability to couple the detection of complex cardiac anatomic abnormalities with coronary artery delineation, serving two important components of the diagnostic evaluation, particularly among patients who will require surgical intervention due to IE complications. Cardiac CTA may be considered as an alternate coronary artery imaging modality in IE patients with low to intermediate risk of disease but meet guideline recommendations for coronary artery imaging.
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http://dx.doi.org/10.1007/s10554-018-1318-0DOI Listing
July 2018

Clinical, Radiographic, and Microbiologic Features of Infective Endocarditis in Patients With Hypertrophic Cardiomyopathy.

Am J Cardiol 2018 02 23;121(4):480-484. Epub 2017 Nov 23.

Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota.

Infective endocarditis (IE) is an infection of the inner lining of the heart with high morbidity and mortality despite medical and surgical advancements in recent decades. Hypertrophic cardiomyopathy (HC) is one of several medical conditions that have been linked to an increased risk of IE, but there is a paucity of data on this association. We therefore sought to define the clinical phenotype of IE in patients with HC at a single tertiary care center. A retrospective cohort of 30 adult patients with HC diagnosed with IE between January 1, 2006 and December 31, 2016 at Mayo Clinic Rochester were identified. Similar rates of aortic (n = 14) and mitral (n = 16) valve involvement by IE were noted (47% vs 53%). This finding persisted even in patients with left-ventricular outflow tract obstruction and systolic anterior motion of the mitral valve. Symptomatic embolic complications occurred in 10 cases (33%). Surgical intervention was performed in 11 cases (37%). One-year mortality was remarkably low at 7%. In conclusion, in the largest single-center cohort of IE complicating HC, there were similar rates of both mitral and aortic valve involvement regardless of the presence of left ventricular outflow tract obstruction, which is contrary to a long-standing tenet regarding the association of HC and IE. Moreover, no "high risk" IE subset was identified based on HC-related parameters.
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http://dx.doi.org/10.1016/j.amjcard.2017.11.010DOI Listing
February 2018

Impacts of a care process model and inpatient electrophysiology service on cardiovascular implantable electronic device infections: a preliminary evaluation.

J Interv Card Electrophysiol 2017 Oct 26;50(1):117-124. Epub 2017 Aug 26.

Division of Infectious Diseases, Mayo Clinic, 200 First St S.W., Rochester, MN, 55905, USA.

Purpose: Cardiovascular implantable electronic device infection (CIEDI) rates are rising. To improve outcomes, our institution developed an online care process model (CPM) and a specialized inpatient heart rhythm service (HRS).

Methods: This retrospective review compared hospital length of stay (LOS), mortality, and times to subspecialty consultation and procedures before and after CPM and HRS availability.

Results: CPM use was associated with shortened time to surgical consultation (median 2 days post-CPM vs. 3 days pre-CPM, p = 0.0152), pocket closure (median 4 vs. 5 days, p < 0.0001), and days to new CIED implant (median 7 vs. 8 days, p = 0.0126). Post-HRS patients were more likely to have a surgical consultation (OR 7.01, 95% CI 1.56-31.5, p = 0.011) and shortened time to pocket closure (coefficient - 2.21 days, 95% CI - 3.33 to - 1.09, p < 0.001), compared to pre-HRS.

Conclusions: The CPM and HRS were associated with favorable outcomes, but further integration of CPM features into hospital workflow is needed.
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http://dx.doi.org/10.1007/s10840-017-0282-2DOI Listing
October 2017

Effect of the American Heart Association 2007 Guidelines on the Practice of Dental Prophylaxis for the Prevention of Infective Endocarditis in Olmsted County, Minnesota.

Mayo Clin Proc 2017 May 10. Epub 2017 May 10.

Division of Infectious Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.

Objective: To determine the adherence of dental providers to the 2007 American Heart Association (AHA) infective endocarditis prevention guidelines regarding antibiotic drug administration before invasive dental procedures.

Patients And Methods: The study included all adults (≥18 years old) with a moderate-risk (MR) or high-risk (HR) cardiac condition who received dental care at participating dental offices from January 1, 2005, through June 1, 2015, in Olmsted County, Minnesota. Data collected included the date and type of dental procedure performed and receipt of antibiotic prophylaxis (AP).

Results: A total of 1351 patients underwent 8854 dental visits at participating dental offices during the study period; 1236 patients had an MR cardiac condition and 115 had an HR condition. The percentage of visits in which antibiotic drugs were used for indicated dental procedures in the MR group declined from 64.6% before to 8.6% after publication of the 2007 AHA guidelines (P<.001); for the HR group, AP declined from 96.9% before to 81.3% after publication of the guidelines (P=.02).

Conclusion: In this historical cohort in Olmsted County there was a statistically significant reduction in AP in the MR group before invasive dental procedures. In addition, there was an unanticipated significant reduction in AP in the HR group after publication of the 2007 AHA guidelines. These findings can be used to provide feedback and education to medical and dental professionals who are involved in decision making regarding the use of dental prophylaxis for their patients.
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http://dx.doi.org/10.1016/j.mayocp.2017.03.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5681438PMC
May 2017

Outcomes in Patients With Cardiovascular Implantable Electronic Device Infection Managed With Chronic Antibiotic Suppression.

Clin Infect Dis 2017 Jun;64(11):1516-1521

Division of Infectious Diseases, Department of Internal Medicine and.

Background.: Most cardiovascular implantable electronic device (CIED) recipients are elderly, have multiple comorbid conditions, and are at increased risk of CIED infection (CIEDI). Current guidelines recommend complete device removal in patients with CIEDI to prevent relapse and mortality. However, comorbidities or other factors may preclude device removal, thus prompting a nonsurgical approach that includes chronic antibiotic suppression (CAS). There are limited data on outcomes of patients receiving CAS for CIEDI.

Methods.: We retrospectively screened 660 CIEDI cases from 2005 to 2015 using electronic health records and a CIEDI institutional database and identified 48 patients prescribed CAS. Primary outcomes were infection relapse and survival.

Results.: The median age was 78 years, and 73% (35/48) were male. The median Charlson comorbidity index was 4. Common pathogens were coagulase-negative staphylococci (21%, 10/48) and methicillin-sensitive Staphylococcus aureus (19%, 9/48). At 1 month after hospitalization, 25% (12/48) of patients had died, of whom only 1 initiated CAS; 67% (8/12) of these had staphylococcal infections. Of the 37 patients who initiated CAS, the most common antimicrobials were trimethoprim-sulfamethoxazole, penicillin, and amoxicillin (22%, 8/37 each). Estimated median overall survival was 1.43 years (95% confidence interval, 0.27-2.14), with 18% (6/33 survivors) developing relapse within 1 year. Of the 6 patients who relapsed, 2 (33%) subsequently underwent CIED extraction.

Conclusion.: CAS is reasonable in select patients who are not candidates for complete device removal for attempted cure of CIEDI. Nevertheless, 1-month mortality in our sample of CAS-eligible patients was high and reflective of high rates of comorbid conditions.
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http://dx.doi.org/10.1093/cid/cix181DOI Listing
June 2017

Prosthetic pulmonary valve and pulmonary conduit endocarditis: clinical, microbiological and echocardiographic features in adults.

Eur Heart J Cardiovasc Imaging 2016 Aug 8;17(8):936-43. Epub 2016 May 8.

Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA.

Aims: To review clinical and microbiological findings in adults with prosthetic pulmonary valve (PPV) or right ventricle to pulmonary artery conduit (RVPAC) infective endocarditis (IE) and to assess the yield of transthoracic (TTE) and transesophageal echocardiography (TEE) as diagnostic tools.

Methods And Results: Seventeen adults (age ≥18 years) with PPV/RVPAC who met diagnostic criteria for definite IE between 2000 and 2015 were included. Median age was 34 years and 29% were females; four patients (24%) had a previous episode of IE. IE occurred a median interval of 5.3 years after PPV/RVPAC insertion; median follow-up time was 206 days. The most common organisms were Staphylococcus aureus (29%), coagulase-negative staphylococci (24%), and streptococcal species (24%). Eleven patients (64.5%) required PPV/RVPAC replacement surgery as consequence of the IE episode. There were three deaths during follow-up; one non-operative and two post-operative. TTE was diagnostic for PPV/RVPAC IE in 10 (62%) and TEE was diagnostic in eight (57%) patients; when combined TTE/TEE were diagnostic in 15 of 17 (88%) cases. Severe PPV/RVPAC obstruction was present at the time of IE diagnosis in nine (53%) and severe regurgitation in five (29%).

Conclusion: PPV/RVPAC IE is associated with significant morbidity, mortality and high risk of requiring operative intervention. TTE and TEE are marginal diagnostic tools when used independently; they should be used as complementary techniques in the evaluation of those patients. Severe PPV/RVPAC stenosis was more common than regurgitation in patients with IE; thus IE should be considered in patients presenting with new PPV/RVPAC obstruction.
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http://dx.doi.org/10.1093/ehjci/jew086DOI Listing
August 2016

Cardiovascular Implantable Electronic Device Infections due to Propionibacterium Species.

Pacing Clin Electrophysiol 2016 Jun 22;39(6):522-30. Epub 2016 Apr 22.

Division of Infectious Diseases, Department of Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.

Introduction: Propionibacterium species are part of the normal skin flora and often considered contaminants when identified in cultures. However, they can cause life-threatening infections, including prosthetic cardiovascular device infections. Clinical presentation and management of cardiovascular implantable electronic device (CIED) infection due to Propionibacterium species has not been well described.

Methods: Retrospective review of all cases of CIED infection due to Propionibacterium species admitted to Mayo Clinic between January 1, 1990 and December 31, 2014. Patient charts were reviewed for clinical, microbiological, and imaging data. Descriptive analysis was performed.

Results: We identified 14 patients with CIED infection due to Propionibacterium species, accounting for 2.3% of all CIED infections. Patients were predominantly male (n = 12, 86%). The median age at admission was 58.5 years (range 22-83). Twelve patients had implantable cardioverter defibrillators (ICDs) and two had permanent pacemaker systems. Twelve patients had generator pocket infection (86%). Two patients met clinical criteria for CIED-related infective endocarditis. Median time between last device manipulation and infection was 9 months (range 1-98). All patients were treated with complete device removal and antibiotic therapy. Six-month follow-up data were available for 10 patients (71%), with no relapses documented.

Conclusion: CIED infections due to Propionibacterium species accounted for 2.3% of all device infections over a 25-year period. The most common infectious syndrome was generator pocket infection with delayed onset. There was an unanticipated predominance of ICDs in this cohort. Cure was achieved in all cases with complete device removal and antibiotic therapy.
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http://dx.doi.org/10.1111/pace.12845DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4889492PMC
June 2016

Beta-haemolytic streptococcal endocarditis: clinical presentation, management and outcomes.

Infect Dis (Lond) 2016 14;48(5):373-8. Epub 2016 Jan 14.

a Division of Infectious Diseases, Department of Medicine , Mayo Clinic College of Medicine , Rochester , MN , USA ;

Background: Beta-haemolytic streptococcal (BHS) endocarditis is rare, but well-recognised for its high morbidity and mortality. This study sought to further characterise clinical features, management and outcomes of BHS endocarditis.

Methods: Retrospective review of all adultpatients (≥ 18 years old) with BHS endocarditis treated at the Mayo Clinic from 1 January 2000 to 31 December 2014.

Results: Forty-nine cases of BHS endocarditis were identified with a mean (± SD) age of 64 (± 14.9) years and 65% were males. The infection was community acquired in 92% of the cases, with a median (IQR) time to diagnosis from symptom onset of 6 days (5-10). Associated conditions included the presence of a prosthetic valve (41%), malignancy (33%) and diabetes mellitus (DM) (31%). Median (IQR) vegetation size was 12 mm (9-17 mm). In a univariate analysis patients with DM had larger vegetations, median (IQR) = 17 mm (10.5-26 mm) compared to non-diabetic patients, median (IQR) = 11 mm (8-15 mm) (p = 0.01). Septic brain emboli occurred in 43% of cases. Eighteen patients (37%) underwent early (within 30 days) surgery. All-cause 1 month and 6 month mortality rates were 25% and 31%, respectively.

Conclusion: BHS endocarditis has an acute onset and is complicated by relatively large vegetations with a high rate of systemic embolisation. DM was the second most common associated medical condition and patients with DM had larger vegetations. Despite medical and surgical advances, mortality due to BHS endocarditis remains high, particularly within 30 days of diagnosis.
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http://dx.doi.org/10.3109/23744235.2015.1129672DOI Listing
December 2016

Infective Endocarditis Involving the Pulmonary Valve.

Am J Cardiol 2015 Dec 9;116(12):1928-31. Epub 2015 Oct 9.

Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota.

Pulmonary valve (PV) infective endocarditis (IE) is a rare entity, accounting for 1.5% to 2% of cases of IE. Published data are limited to a few case series and reports. We sought to review the Mayo Clinic experience and describe clinical, echocardiographic, and microbiologic features. We included all patients aged ≥18 years seen from 2000 to 2014 who had a diagnosis of native PV IE and unequivocal echocardiographic involvement of the PV. Nine patients with PV IE were identified. Isolated PV IE was present in 7 (78%) of 9 cases. The median age was 59 years and 22% were women. Three patients had congenital heart disease, 2 had central venous catheters, and 3 had cardiovascular implantable electronic devices. Five patients (56%) received chronic immunosuppressive therapy. Enterococcus faecalis and viridans group streptococci were the most common pathogens, isolated in 22% of cases each. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) were done in 6 and 7 patients, respectively. Four patients underwent both procedures. TTE was diagnostic in all cases, but TEE failed to detect PV involvement in 1 patient. Median follow-up was 1.8 years. Five patients (56%) underwent PV replacement. There were no operative deaths. One patient had sudden death during follow-up, unrelated to his PV IE episode. Our results suggest that PV IE is rare but carries significant morbidity. TTE and TEE provide complementary information with TEE providing better visualization of other cardiac structures. Our findings of a high prevalence of immunosuppressive therapy and cardiovascular implantable electronic devices have not been previously reported and deserve further investigation.
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http://dx.doi.org/10.1016/j.amjcard.2015.09.038DOI Listing
December 2015

Clinical Presentation, Risk Factors, and Outcomes of Hematogenous Prosthetic Joint Infection in Patients with Staphylococcus aureus Bacteremia.

Am J Med 2016 Feb 8;129(2):221.e11-20. Epub 2015 Oct 8.

Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.

Background: Staphylococcus aureus bacteremia is a life-threatening condition that may lead to metastatic infection, including prosthetic joint infection.

Methods: To assess clinical factors associated with hematogenous prosthetic joint infection, we retrospectively reviewed all patients with a joint arthroplasty in place at the time of a first episode of S. aureus bacteremia over a 5-year period at our institution. Patients with postsurgical prosthetic joint infection without hematogenous prosthetic joint infection were excluded.

Results: There were 85 patients (143 arthroplasties) with either no prosthetic joint infection (n = 50; 58.8%) or hematogenous prosthetic joint infection in at least one arthroplasty (n = 35; 41.2%). The odds of hematogenous prosthetic joint infection was significantly increased among patients with community-acquired S. aureus bacteremia (odds ratio [OR] 18.07; 95% confidence interval [CI] 2.64-infinity; P = .001), as compared with nosocomial S. aureus bacteremia, in which there were no patients with hematogenous prosthetic joint infection. After adjusting for S. aureus bacteremia classification, the presence of ≥3 joint arthroplasties in place was associated with a nearly ninefold increased odds of hematogenous prosthetic joint infection as compared with those with 1-2 joint arthroplasties in place (OR 8.55; 95% CI 1.44-95.71; P = .012). All but one joint with prosthetic joint infection demonstrated at least one clinical feature suggestive of infection. There were 4 additional S. aureus prosthetic joint infections diagnosed during a median of 3.4 years of follow-up post hospitalization for S. aureus bacteremia.

Conclusion: Prosthetic joint infection is frequent in patients with existing arthroplasties and concomitant S. aureus bacteremia, particularly with community-acquired S. aureus bacteremia and multiple prostheses. In contrast, occult S. aureus prosthetic joint infection without clinical features suggestive of prosthetic joint infection at the time of S. aureus bacteremia is rare.
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http://dx.doi.org/10.1016/j.amjmed.2015.09.006DOI Listing
February 2016

Temporal trends in infective endocarditis epidemiology from 2007 to 2013 in Olmsted County, MN.

Am Heart J 2015 Oct 17;170(4):830-6. Epub 2015 Jul 17.

Division of Infectious Diseases, Mayo Clinic, Rochester, MN.

Background: The aim of this study is to determine if there have been contemporary shifts in infective endocarditis (IE) epidemiology in our local population; an analysis of cases from 2007 to 2013 was conducted.

Methods: This is a population-based review of all adults (≥18 years) residing in Olmsted County, MN, with definite or possible IE using the Rochester Epidemiology Project from January 1, 2007, to December 31, 2013.

Results: We identified 51 cases of IE in Olmsted County, MN, between 2007 and 2013. Median age of IE cases was 68.8 years (interquartile range 55.6-76.5), and 41% were females. Age- and sex-adjusted incidence of IE was 7.4 (95% CI 5.3-9.4) cases per 100,000 person-years. From a multivariable Poisson regression model, incidence of IE did not change significantly during the study period (P = .222) but was significantly higher in males and those of older age (P < .001). The annual incidences (per 100,000 person-years) were 2.5 for Staphylococcus aureus, 1.1 for viridans group streptococci, 1.6 for Enterococcus species, and 0.8 for coagulase-negative staphylococci. Only 19.6% (10/51) of Olmsted County patients underwent valve surgery between 2007 and 2013 as compared with 44.4% (197/444) of non-Olmsted County patients treated at Mayo Clinic Rochester.

Conclusion: In this population-based study, no significant change in the overall incidence of IE in Olmsted County, MN, between 2007 and 2013 was seen, and it was similar to that seen between 1970 and 2006. Male gender and older age were associated with increased IE risk. With a lesser extent of cases attributable to viridans group streptococcal IE compared with previous years, S aureus was the predominant pathogen in IE cases during 2007 to 2013. The relatively low valve surgery rate was disparate from that reported from large, tertiary care centers (including our own) with non-population-based cohorts, which are subject to referral bias and can influence the expected characterization of IE.
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http://dx.doi.org/10.1016/j.ahj.2015.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4677064PMC
October 2015

Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association.

Circulation 2015 Oct 15;132(15):1435-86. Epub 2015 Sep 15.

Background: Infective endocarditis is a potentially lethal disease that has undergone major changes in both host and pathogen. The epidemiology of infective endocarditis has become more complex with today's myriad healthcare-associated factors that predispose to infection. Moreover, changes in pathogen prevalence, in particular a more common staphylococcal origin, have affected outcomes, which have not improved despite medical and surgical advances.

Methods And Results: This statement updates the 2005 iteration, both of which were developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It includes an evidence-based system for diagnostic and treatment recommendations used by the American College of Cardiology and the American Heart Association for treatment recommendations.

Conclusions: Infective endocarditis is a complex disease, and patients with this disease generally require management by a team of physicians and allied health providers with a variety of areas of expertise. The recommendations provided in this document are intended to assist in the management of this uncommon but potentially deadly infection. The clinical variability and complexity in infective endocarditis, however, dictate that these recommendations be used to support and not supplant decisions in individual patient management.
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http://dx.doi.org/10.1161/CIR.0000000000000296DOI Listing
October 2015

Genitourinary Procedures as Risk Factors for Prosthetic Hip or Knee Infection: A Hospital-Based Prospective Case-Control Study.

Open Forum Infect Dis 2015 Sep 30;2(3):ofv097. Epub 2015 Jun 30.

Division of Infectious Diseases.

Background.  The purpose of this study was to determine the risk of prosthetic joint infection (PJI) as a complication of routine genitourinary (GU) procedures in patients with total hip arthroplasty (THA) or total knee arthroplasty (TKA) and to study the impact of antibiotic prophylaxis administered prior to these procedures. Methods.  We conducted a prospective, single-center, case-control study between December 1, 2001 and May 31, 2006. Case patients were hospitalized with total hip or knee PJI. Control subjects underwent a THA or TKA and were hospitalized during the same period on the same orthopedic floor without a PJI. Data regarding demographic features and potential risk factors were collected. The outcome measure was the odds ratio (OR) of PJI after GU procedures performed within 2 years of admission. Results.  A total of 339 case patients and 339 control subjects were enrolled in the study. Of these, 52 cases (15%) and 55 controls (16%) had undergone a GU procedure in the preceding 2 years. There was no increased risk of PJI for patients undergoing a GU procedure with or without antibiotic prophylaxis (adjusted OR [aOR] = 1.0, 95% confidence interval [CI] = 0.2-4.5, P = .95 and aOR = 1.0, 95% CI = 0.6-1.7, P = .99, respectively). Results were similar in a subset of patients with a joint age less than 6 months, less than 1 year, or greater than 1 year. Conclusions.  Genitourinary procedures were not risk factors for subsequent PJI. The use of antibiotic prophylaxis before GU procedures did not decrease the risk of subsequent PJI in our study.
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http://dx.doi.org/10.1093/ofid/ofv097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4525011PMC
September 2015

Incidence of Infective Endocarditis Due to Viridans Group Streptococci Before and After the 2007 American Heart Association's Prevention Guidelines: An Extended Evaluation of the Olmsted County, Minnesota, Population and Nationwide Inpatient Sample.

Mayo Clin Proc 2015 Jul;90(7):874-81

Division of Infectious Diseases, Mayo Clinic, Rochester, MN.

Objective: To determine whether the incidence of infective endocarditis (IE) due to viridans group streptococci (VGS) increased after the publication of the 2007 American Heart Association (AHA) IE prevention guidelines.

Patients And Methods: We performed a population-based survey of all adults (18 years and older) residing in Olmsted County, Minnesota, from January 1, 1999, through December 31, 2013, to identify definite or possible cases of VGS-IE using the Rochester Epidemiology Project. The National (Nationwide) Inpatient Sample hospital discharge database was examined to determine the number of VGS-IE cases in the United States between 2000 and 2011.

Results: Rates of incidence (per 100,000 person-years) during the intervals of 1999-2002, 2003-2006, 2007-2010, and 2011-2013 were 3.6 (95% CI, 1.3-5.9), 2.7 (95% CI, 0.9-4.4), 0.7 (95% CI, 0.0-1.6), and 1.5 (95% CI, 0.2-2.9), respectively, reflecting an overall significant decrease (P=.03 from Poisson regression). Likewise, nationwide estimates of hospital discharges with a VGS-IE diagnosis trended downward during 2000-2011, with a mean number per year of 15,853 and 16,157 for 2000-2003 and 2004-2007, respectively, decreasing to 14,231 in 2008-2011 (P=.05 from linear regression using weighted least squares method).

Conclusion: Despite major reductions in the number of indications for antibiotic prophylaxis for invasive dental procedures espoused by the 2007 AHA IE prevention guidelines, both local and national data indicate that the incidence of VGS-IE has not increased.
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http://dx.doi.org/10.1016/j.mayocp.2015.04.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560595PMC
July 2015

Association of Mitral Valve Prolapse With Infective Endocarditis Due to Viridans Group Streptococci.

Clin Infect Dis 2015 Aug 11;61(4):623-5. Epub 2015 May 11.

Division of Infectious Diseases Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.

Although patients with certain cardiac valve abnormalities have increased risk of infective endocarditis (IE), it is unknown whether these abnormalities are associated with specific pathogens in IE cases. We report a strong association between mitral valve prolapse and viridans group streptococcal IE in a population-based cohort from Olmsted County, Minnesota.
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http://dx.doi.org/10.1093/cid/civ375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542600PMC
August 2015

Predicting Risk of Endocarditis Using a Clinical Tool (PREDICT): Scoring System to Guide Use of Echocardiography in the Management of Staphylococcus aureus Bacteremia.

Clin Infect Dis 2015 Jul 25;61(1):18-28. Epub 2015 Mar 25.

Division of Infectious Diseases Division of Cardiovascular Diseases, Department of Medicine.

Background: Infective endocarditis (IE) is a serious complication of Staphylococcus aureus bacteremia (SAB). There is limited clinical evidence to guide use of echocardiography in the management of SAB cases.

Methods: Baseline and 12-week follow-up data of all adults hospitalized at our institution with SAB from 2006 to 2011 were reviewed. Clinical predictors of IE were identified using multivariable logistic regression analysis.

Results: Of the 757 patients screened, 678 individuals with SAB (24% community acquired, 56% healthcare associated, and 20% nosocomial) met study criteria. Eighty-five patients (13%) were diagnosed with definite IE within the 12 weeks of initial presentation based on modified Duke criteria. The proportion of patients with IE was 22% (36/166) in community-acquired SAB, 11% (40/378) in community-onset healthcare-associated SAB, and 7% (9/136) in nosocomial SAB. Community-acquired SAB, presence of cardiac device, and prolonged bacteremia (≥ 72 hours) were identified as independent predictors of IE in multivariable analysis. Two scoring systems, day 1 (SAB diagnosis day) and day 5 (when day 3 culture results are known), were derived based on the presence of these risk factors, weighted in magnitude by the corresponding regression coefficients. A score of ≥ 4 for day 1 model had a specificity of 96% and sensitivity of 21%, whereas a score of <2 for day 5 model had a sensitivity of 98.8% and negative predictive value of 98.5%.

Conclusions: We propose 2 novel scoring systems to guide use of echocardiography in SAB cases. Larger prospective studies are needed to validate the classification performance of these scoring systems.
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http://dx.doi.org/10.1093/cid/civ235DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542912PMC
July 2015

Predicting risk of endovascular device infection in patients with Staphylococcus aureus bacteremia (PREDICT-SAB).

Circ Arrhythm Electrophysiol 2015 Feb 12;8(1):137-44. Epub 2014 Dec 12.

From the Division of Infectious Diseases, Department of Medicine (M.R.S., B.R.P., S.K.,W.R.W., J.M.S, L.M.B.), Division of Cardiovascular Diseases, Department of Medicine (M.R.S., P.A.F., D.L.H., L.M.B.), Department of Biostatistics and Informatics (C.M.L.), Mayo Clinic College of Medicine, Rochester, MN; Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles (D.Z.U.); and Department of Medicine, University of Florida Health Science Center, Jacksonville (F.A.-S.).

Background: Prompt recognition of underlying cardiovascular implantable electronic device (CIED) infection in patients presenting with Staphylococcus aureus bacteremia (SAB) is critical for optimal management of these cases. The goal of this study was to identify clinical predictors of CIED infection in patients presenting with SAB and no signs of pocket infection.

Methods And Results: All cases of SAB in CIED recipients at Mayo Clinic from 2001 to 2011 were retrospectively reviewed. We identified 131 patients with CIED who presented with SAB and had no clinical signs of device pocket infection. Forty-five (34%) of these patients had underlying CIED infection based on clinical or echocardiographic criteria. The presence of a permanent pacemaker rather than an implantable cardioverter-defibrillator (odds ratio, 3.90; 95% confidence interval, 1.65-9.23; P=0.002), >1 device-related procedure (odds ratio, 3.30; 95% confidence interval, 1.23-8.86; P=0.018), and duration of SAB ≥4 days (odds ratio, 5.54; 95% confidence interval, 3.32-13.23; P<0.001) were independently associated with an increased risk of CIED infection in a multivariable model. The area under the receiver operating characteristics curve for the multivariable model was 0.79, indicating a good discriminatory capacity to distinguish SAB patients with and without CIED infection.

Conclusions: Among patients presenting with SAB and no signs of pocket infection, the risk of underlying CIED infection can be calculated based on the type of device, number of device-related procedures, and duration of SAB. We propose that patients without any of these high-risk features have a low risk of underlying CIED infection and may be monitored closely without immediate device extraction. Prospective studies are needed to validate this risk prediction model.
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http://dx.doi.org/10.1161/CIRCEP.114.002199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4334722PMC
February 2015