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The authors studied the etiology, outcome and risk factors of 339 cases of infective endocarditis (IE) in Slovakia over the last 10 years. Aortic valve was infected in 59.9%, mitral in 38.1% and tricuspidal/pulmonary in 5.0% of cases. The majority of IE were caused by staphylococci (29.2%), 15.0% were due to viridans streptococci, 7.4% due to Enterococcus faecalis, 3.9% due to the HACEK group (Haemophilus spp., Actinobacillus spp., Corynebacterium spp., Eikenella spp., Kingella spp.) and 39.2% were culture negative. The following risk factors were the most frequently identified: rheumatic fever in 24.2%, dental surgery in 13.3%, previous cardiosurgery in 7.1% and neoplasia in 7.1%. All patients were treated with antimicrobials and 42.5% of patients also with surgery (valvular prosthesis replacement): 61 (18.0%) died, and 278 (82.0%) survived at day 60 after the diagnosis of endocarditis was made. Univariate analysis did not show significant differences in most of the recorded risk factors between patients who died and those who survived: apart from staphylococcal etiology (44.3% vs. 26.6%, P < 0.01), persistent bacteremia (with three or more positive blood cultures 24.6% vs. 9.7% P < 0.002) which were significantly associated with higher attributable mortality, as was absence of surgery (55.7% vs. 6.1% P < 0.001), whereas antibiotic therapy in combination with surgery significantly predicted better outcome (P < 0.001). We compared risk factors, etiology, therapeutic strategies and outcome of IE in two periods: from 1991-1997 (180 cases) and from 1998-2001 (159 cases). Rheumatic fever was less commonly observed in second period (1998-2001) P < 0.01 since its prevalence in Slovakia is rapidly decreasing. Dental surgery was less frequent as well (20.5% vs. 5.0% P < 0.001). There was a significant shift in etiology within the second study period: negative-culture endocarditis (despite better bacteriological techniques) (P < 0.001) was more frequently observed in the 1st period and represented 53.3% of all cases in 1998-2001 in comparison to 26.7% in 1991-1997. Enterococci (P < 0.0002) were also more frequent in the 2nd period. Persistent bacteremia (3 or more positive blood cultures 20.5% vs. 3.1%, P < 0.001 was less commonly observed within the 2nd period (1998-2001) in comparison to 1991-1997. More patients in the second period (1998-2001) had complications of IE (P < 0.001) than in the 1st period. However mortality was lower (22.2% vs. 13.2%, P < 0.044) because of more surgical intervention in the 2nd period (52.8% vs. 33.3%, P < 0.001).

Our findings suggest that patients aged ≥75 years or those with the presence of diabetes mellitus, dementia, hypercholesterolemia or polypharmacy were likely to be persistent with statin therapy, whereas those with anxiety disorders may need greater assistance with persistence of statin therapy. Copyright © 2016 John Wiley & Sons, Ltd.

Fifty-three cases of staphylococcal endocarditis from a national endocarditis survey were analyzed for risk factors and outcome. Thirty of 53 patients had predisposing heart disease (39.6% rheumatic fever) but only 3 were on dialysis, only 2 had central venous catheter, only 2 intravenous drug abuse but 7 had prior cardiosurgery. Mortality was 39.6%. In analyzing risk factors for death, attributable mortality was significantly associated with skin infections (P < 0.05), embolization (P < 0.02), inappropriate therapy (P < 0.005) either because of too short therapy (P < 0.003) or wrong antibiotic combination (P < 0.01). Surgical therapy was associated with better outcome (4.8% deaths vs. 31.2% survivors, P < 0.04).

The aim of this study was to assess trends in risk factors, etiology, outcome and treatment strategies for endocarditis over 23 years in Slovakia. A prospective survey of 606 cases of infective endocarditis (IE) was conducted from 1984-2006. Rheumatic fever as well as previous dental surgery showed decreasing trends within the last 23 years. Also embolic complications of IE declined along with increasing rates of surgically treated patients. No significant changes in etiology were detected apart from the fact that culture-negative endocarditis increased from 10.7% to 55.4% between 1998-2001. Surgically treated patients increased from 22.7% (1984-1990) to 50.1% (2002-2006) and mortality dramatically decreased from 26.7% (1984-1990) to 5.3% (2002-2006). Staphylococcus aureus and coagulase-negative staphylococci were the leading causes (22.4% - 48%) followed by viridans streptococci (12.2%-18.2%) were a relatively stable trend over 23 years of IE in Slovakia.

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The most common etiologic agents of infective endocarditis are Gram-positive bacteria -staphylococci, viridans streptococci, and enterococci, which represent 50-70% of all bacterial isolates from blood cultures in patients with infective endocarditis. Culturenegative infective endocarditis represents 25-40% and Gramnegative bacteria 5-10%. [1][2][3][4] We assessed the proportion, etiology, risk factors, and mortality of infective endocarditis due to Gram-negative bacteria within our database of infective endocarditis in Slovakia. Endocarditis was defined according to the modified Duke criteria.Out of 606 cases of infective endocarditis, 42 cases due to Gramnegative bacteria were found (6.9%). The organisms isolated in the 42 cases were: Pseudomonas aeruginosa (8), Haemophilus influenzae (6), Acinetobacter baumannii (6), Klebsiella pneumoniae (6), Salmonella enteritidis (5), Pantoea agglomerans (4), Escherichia coli (4), Citrobacter freundii (1), Serratia marcescens (1), and Pseudomonas fluorescens (1).A comparison of the 564 cases of non-Gram-negative infective endocarditis with the 42 cases of Gram-negative endocarditis, in univariate analysis, is shown in Table 1. Diabetes mellitus type I (10.3% vs. 26.2%; p = 0.002), prior endoscopy (6.4% vs. 31%; p = 0.001), congenital heart disease (2.7% vs. 11.9%; p = 0.001), dental surgery (12.4% vs. 23.8%; p = 0.04), and right side (2% vs. 9.5%; p = 0.002), were significantly more frequent in those with Gram-negative endocarditis. In contrast, prosthetic valve insertion (15.8% vs. 2.4%; p = 0.02) was less frequently observed among infective endocarditis cases due to Gram-negative bacteria than among non-Gram-negative cases. The mortality rate was similar in both groups (15.4% vs. 9.5%; not significant). The proportion of infective endocarditis due to Gram-negative bacteria (6.9%) over the course of 23 years in Slovakia is similar to the proportion of Gram-negative infective endocarditis (5-10%) from other national studies in Europe. [2][3][4] Patients with diabetes mellitus type I, those having undergone endoscopy of the gastrointestinal or genitourinary tract, those with congenital heart disease, those having had dental surgery, and those with right-sided endocarditis are at higher risk of Gramnegative infective endocarditis. Therefore initial therapy with an anti-Gram-negative antibiotic until etiology/susceptibility is determined is advisable.

Dear Sir, Staphylococci are responsible for 30 to 50% of all infective endocarditis (IE) both in Europe and the US [1 Á3] and the trend of IE due to staphylococci is increasing. However, there is ongoing discussion on the diagnostic value of coagulase negative staphylococci in blood cultures [1 Á3]. In our national survey within last 22 y, 154 of 606 from all IE (24.9%) were due to staphylococci and the majority of them due to S. aureus (55%) ( Table I), which was responsible for 85 IE episodes (14%) of all 604 cases. Coagulase negative staphylococci (CoNS) were responsible for 69 episodes, which represents 44.8% of staphylococcal and 11.4% of all IE. 50 cases were due to S. epidermidis, 7 S. hominis, 2 S. auricularis, 2 S. lugdunensis, 1 S. xylosus, 1 S. saprophyticus, 2 S. haemolyticus, 2 S. warneri, 1 S. simulans and 1 S. acidominimus (Table I). Only 3 S. aureus (3.5%) were methicillin resistant (MRSA) in contrast to 20 of 69 coagulase negative staphylococci (28.1%) which were methicillin resistant and 14% clindamycin resistant. However, all isolates were susceptible to tetracycline, cotrimoxazole (TMP/ SMX), vancomycin, teicoplanin and rifampin.Concerning risk factors, several of them were observed more frequently in the S. aureus IE and IE due to CoNS groups compared to all 606 cases of IE. In the population of diabetic patients (20.1% vs 11.4%, pB0.045) and patients with prosthetic valve IE (38.8% vs 14.9%, pB0.045), infective endocarditis was more frequently caused by S. aureus. Previous cardiosurgery (42.3% and 45.3% vs 9.9%, pB0.001) and pre-existing congenital or acquired heart disease (18.5% and 19.5% vs 3.3%, pB0.001) are common risk factors for both S. aureus IE and IE due to CoNS. However, mortality was higher in S. aureus IE (pB0.045) compared to all cases (25.8% vs 15%) and also in embolization due to CoNS (25.8% vs 7.1%). In contrast, mortality due to coagulase negative staphylococci was significantly lower (7.1%) compared to S. aureus and the whole group of IE, probably because of a lower proportion of rheumatic fever (1.3% vs 22.3%, pB0.01) and embolization (5.7% vs 35.5%, pB0.001) (Table II).