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#Endocardite #Epidemiologie #Metabolomique #These
S treptococcal bloodstream infections (BSIs) are among the most frequent causes of infective endo- carditis (IE) and large registry studies have demon- strated either an increased or an unchanged prevalence of streptococcal IE across the last decades. 1–3
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#Endocardite #Epidemiologie #Metabolomique #These
Whereas Staphylococcus aureus IE is most common in large re- ferral center studies, 4 a recent population-based nation- wide study from Spain found that streptococcal IE was still more frequent than Staphylococcus aureus IE. 5
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#Endocardite #Epidemiologie #Metabolomique #These
Without providing any details of streptococcal species, a newly published large popula- tion-based study found that 7.3% of streptococcal BSIs were associated with IE-hospitalization. 3
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#Endocardite #Epidemiologie #Metabolomique #These
Furthermore, the European Society of Cardiology guideline’s diagnostic criteria for IE are primarily based on the modified Duke criteria, including blood cultures with only viridans streptococci or S bovis as a diagnostic major criterion for strepto- coccal IE. 10,12 The term viridans is based on the bacterial culture causing green hemolysis on blood agar plates and is outdated and inconsistent since some of the in- cluded streptococcal species do not cause hemolysis and other species are able to produce several different kinds of hemolysis. 13
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#Endocardite #Epidemiologie #Metabolomique #These
Based on phylogenetic relationship, determined by 16-rRNA gene sequencing, the streptococci were classified on species level and divided into 8 main groups (Figure 1).
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#Endocardite #Epidemiologie #Metabolomique #These
S pneumoniae is phylogenetically related to the Mitis group, but is usually either analyzed separately or not included when evaluating streptococcal IE, thus we analyzed S pneumoniae separately. 19–21
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#Endocardite #Epidemiologie #Metabolomique #These
S oralis and S mitis were analyzed together because of very close phylo- genetic relationship and since the microbiological result often is reported as S mitis/oralis
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#Endocardite #Epidemiologie #Metabolomique #These
In our study, unclassified streptococci such as S suis, S acidominimus, and S ovis were pooled together with nutritionally variant streptococci, including Granulicatella adiacens (G adiacens), Granulicatella paraadiacens (G paraadiacens), Granulicatella elegans (G elegans), and Abiotrophia defectiva. This group was called “other streptococci.”
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#Endocardite #Epidemiologie #Metabolomique #These
As a result of very few cases and close phylogenetic relation, S cristatus and S sinensis from the Mitis group were also analyzed in combination.
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#Endocardite #Epidemiologie #Metabolomique #These
The index date of each case was the date of obtain- ing the positive blood cultures and positive blood cultures occurring within 14 days were considered as part of the same episode of BSI.
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[THESE] - Chamat-Hedemand et al. - 2020 - Prevalence of Infective Endocarditis in Streptococ.pdf
#Endocardite #Epidemiologie #Metabolomique #These #has-images
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#Endocardite #Epidemiologie #Metabolomique #These
Therefore, when defining patients with IE, we used a criterion of minimum 2 weeks admission to reduce the number of false-positive diagnoses and obtain a positive predictive value >90% as earlier demonstrated in the Danish registries. 22,23 To account for IE deaths occurring within the first 2 weeks we also included all patients with an IE diag- nosis who died within the first 14 days of admission.
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#Endocardite #Epidemiologie #Metabolomique #These
IE was considered related to the streptococcal BSI when the positive blood cultures occurred within the IE admission or up to 30 days before the IE admission.
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#Endocardite #Epidemiologie #Metabolomique #These
In a sensitivity analysis, a BSI was considered part of the same disease-course if the same species was identified within 21 days instead of the original 14 days. Furthermore, in a sensitivity analysis of the IE association, the period from BSI to IE admission was varied from 30 days to 14 and 60 days, alternately. In a third sensitivity analysis we included only the first BSI case of an IE episode.
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#Endocardite #Epidemiologie #Metabolomique #These
The prevalence of IE in the total cohort was 7.1% (95% CI, 6.5–7.8). The mean age of patients with IE was 69.0 years (SD 14.8) and 66.0% were men
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#Endocardite #Epidemiologie #Metabolomique #These
In the Mitis group (without S pneumoniae) the prevalence of IE was 23.8% with a range from 0% to 44% depending on the specific species. In the Pyogenic group the combined prevalence of IE was 5.6% with a range of 2% to 9%. In the Anginosus group the prevalence was 4.2% with a spread in different spe- cies from 0% to 5%. In the Bovis group the aggregated IE prevalence was 26.9% ranging from 0% to 30% between the species. In the Salivarius group the IE prevalence was 5.7% with a range from 4% to 7% and in the group of other streptococci the prevalence of IE was 8.8% ranging from 0% to 12%
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#Endocardite #Epidemiologie #Metabolomique #These
In BSIs caused by the most common streptococcal spe- cies, S pneumoniae and S pyogenes had a low (<%) prevalence of IE; S dysgalactiae, S anginosus, and S agalactiae had a moderate (3% to 10%) prevalence of IE; and S mitis/oralis a high (10% to 30%) prevalence of IE (Figure 3)
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#Endocardite #Epidemiologie #Metabolomique #These
In the moderately common causes of BSI, the IE prevalence was very high (>30%) in S gal- lolyticus, S sanguinis, and S gordonii.
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#Endocardite #Epidemiologie #Metabolomique #These
In the total cohort of patients with IE, 20.3% (n=94) un- derwent valve replacement surgery, where patients with S gordonii IE (n=13, 31.0%) had the highest prevalence of surgery whereas patients with S dysgalactiae IE (n=7, 12.1%) had the lowest prevalence
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[unknown IMAGE 7074014432524]
[THESE] - Chamat-Hedemand et al. - 2020 - Prevalence of Infective Endocarditis in Streptococ.pdf
#Endocardite #Epidemiologie #Metabolomique #These #has-images
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#Endocardite #Epidemiologie #Metabolomique #These
The overall 1-year mortality in patients with IE was 22.7% (n=105), with the highest mortality in patients with S dysgalactiae IE (n=17, 29.3%) and the lowest mortality in patients with S gallolyticus IE (n=9, 13.2%; Figure II in the Data Supplement).
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#Endocardite #Epidemiologie #Metabolomique #These
A multivariable logistic regression analysis was per- formed, adjusted for potential confounders, to assess the risk of IE according to host factors and infecting species. It showed that ≥3 positive blood culture bot- tles, prosthetic valve, native valve disease, cardiac de- vice, and male sex were significantly associated to IE (Figure 4A).
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#Endocardite #Epidemiologie #Metabolomique #These
The 3 main findings were: (1) the risk of IE was dependent on the infecting strepto- coccal species; (2) the most common streptococcal BSIs had a relatively low prevalence of IE; and (3) the varia- tion in IE prevalence within streptococcal groups was substantial and therefore the risk of IE should be evalu- ated on species level
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#Endocardite #Epidemiologie #Metabolomique #These
When evaluat- ing the IE prevalence diagram (Figure 3), it is evident that the most common BSIs have a low to moderate IE risk. However, when assessing the burden of IE cases (size of the circle) it should be considered that S agalactiae and S dysgalactiae contribute a considerable number of IE cases despite their moderate prevalence.
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#Endocardite #Epidemiologie #Metabolomique #These
In line with earlier studies, S mitis/oralis is a common BSI with a high IE prevalence and in our study the most frequent cause of IE. In the moderately common BSIs, S gallolyticus, S sanguinis, and S gordonii all have a very high IE risk, and each contribute to a substantial amount of IE cases
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#Endocardite #Epidemiologie #Metabolomique #These
In our study, patients infected with some of the high-risk species were older (S mutans, S gallolyticus, and S san- guinis) whereas other high-risk patients had a lower mean age (S mitis/oralis and S gordonii). This diver- gence in age was further illustrated by the fact that age did not independently predict IE in our multivariable model. This result is in line with earlier studies assess- ing the risk of IE in patients with bloodstream infec- tion without finding age to be an independent predic- tor of IE. 19,24–26
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#Endocardite #Epidemiologie #Metabolomique #These
To approach this chal- lenge, Sunnerhagen et al created a score (the HANDOC score) based on 339 non-β-hemolytic streptococcal BSI cases including 26 cases of IE. 19 The HANDOC score is aimed to guide the use of echocardiography by evalu- ating 6 factors: heart murmur or valvular disease, etiol- ogy, number of cultures, duration of symptoms, only 1 species, and community acquisition. External valida- tion of the score showed a high sensitivity. 27 However, the study was limited by only including few IE cases, not including all the different streptococcal species, not differentiating between when to perform TTE or TEE, and identifying zero cases of S anginosus IE (0 of 105 BSIs). 19
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#Endocardite #Epidemiologie #Metabolomique #These
In both Staphylococcus aureus and Enterococcus faecalis (E faecalis) BSIs, a more extensive use of echo- cardiography has been recommended based on studies finding IE prevalence around 15% to 25%. 24,28,29 Fur- thermore, a newly published nationwide study found an IE prevalence of 16.7% in E faecalis, 10.1% in Staphylococcus aureus, and 7.3% in streptococcal BSIs, leading the authors to suggest that screening for IE in all these patients seems reasonable. 3
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#Endocardite #Epidemiologie #Metabolomique #These
In addition to the clinical evaluation we sug- gest to avoid using the term viridans streptococci and rather stratify patients in accordance with streptococ- cal species and associated IE risk.
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#Endocardite #Epidemiologie #Metabolomique #These
Based on our find- ings, we find it reasonable to perform TTE and TEE in all patients with streptococcal BSIs with high or very high risk of IE.
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#Endocardite #Epidemiologie #Metabolomique #These
In streptococci with a low IE prevalence it seems ade- quate to anticipate the clinical course and only per- form echocardiography up front in case of either high or persistent clinical suspicion
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#Endocardite #Epidemiologie #Metabolomique #These
Data on TTE and TEE were not available in the registries. Since echo- cardiography is central in diagnosing IE it is relevant to know if certain species were less often examined with echocardiography thereby increasing the likelihood of missed IE cases. In this light, the prevalence of IE should be interpreted as conservative estimates.
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#Diagnostic #Endocardite #Metabolomique #These
Sensitivities for the diagnosis of IE were 56% and 76% for von Reyn and Duke criteria, respectively.
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#Diagnostic #Endocardite #Metabolomique #These
Fifty-two patients were correctly classified as “probable IE” by von Reyn and “definite IE” by Duke criteria (group 1). However, discrepancies were observed in 41 patients. Eleven patients (group 2) were misclassified as “rejected” by von Reyn, but were “definite IE” by Duke criteria; this difference could be explained by negative blood cultures and positive echocardiogram in all patients.
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#Diagnostic #Endocardite #Metabolomique #These
In eight patients (group 3), the diagnosis of IE was “possible” by von Reyn but “definite” by Duke criteria. This difference was essentially explained by the failure of the von Reyn classification to consider echocardiographic abnormalities as major criteria.
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#Diagnostic #Endocardite #Metabolomique #These
Twenty-two patients (group 4) were misclassified as possible IE using Duke criteria, being false negative of this classification. Echocardiographic major criteria were present in 19 patients, but blood cultures were negative in 21 patients. The cause of negative blood cultures was prior antibiotic therapy in 11 patients and Q-fever endocarditis diagnosed by positive serology in three cases.
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#Diagnostic #Endocardite #Metabolomique #These
Twenty-four percent of patients with proved IE remain misclassified as “possible IE” despite the use of Duke criteria, especially in cases of culture-negative and Q-fever IE
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#Diagnostic #Endocardite #Metabolomique #These
More recently, a new classification including echocardiographic criteria was proposed by Durack et al. (Duke criteria [DC]) and was shown to be more sensitive than the von Reyn criteria (VRC) for the diagnosis of IE (4). Unfortunately, transesophageal echocardiography (TEE) was not performed in all patients in the initial series of Durack, and some patients remain misclassified even with the use of Duke criteria.
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#Diagnostic #Endocardite #Metabolomique #These
only the study group of 93 patients with pathologic confir- mation was considered as the reference for the diagnosis of IE and was used to assess the value of diagnostic criteria.
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#Diagnostic #Endocardite #Metabolomique #These
Infective endocarditis involved a native valve in 63 patients, and a prosthetic valve in 30. Transthoracic echocardiogra- phy (TTE), BC and TEE were performed in all.
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#Diagnostic #Endocardite #Metabolomique #These
Major bacteriologic criteria were BC positive for typical endocar- dial pathogens or persistently positive for microorganisms consistent with IE. Because Q-fever endocarditis has a particularly high incidence in our country, special attention was paid to the diagnosis of this form of IE, either by direct isolation or by serologic procedure (7)
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#Diagnostic #Endocardite #Metabolomique #These
Blood cultures were positive in 60 (64%) patients, Strep- tococci (n 5 32) and Staphylococci (n 5 21) being the most frequently observed organisms; Q-fever endocarditis was identified in four patients. Thirty-three (36%) patients had culture-negative IE
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#Diagnostic #Endocardite #Metabolomique #These
Using DC, IE was considered “definite” in the presence of either two major criteria, or one major and three minor criteria, or five minor criteria. Major and minor criteria were defined according to the Duke classification (4).
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#Diagnostic #Endocardite #Metabolomique #These
Using VRC, IE was considered “probable,” “possible” or “rejected” on the basis of the initial definitions of von Reyn (1)
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#Diagnostic #Endocardite #Metabolomique #These
According to these classifications, patients were separated into four groups (Table 1): ● Group 1 includes 52 patients correctly classified as “prob- able” IE by VRC and “definite” IE by DC; ● Group 2 includes 11 patients in whom the diagnosis of IE was “rejected” by VRC but was “definite” by DC; ● Group 3 includes eight patients in whom IE was “possi- ble” by VRC but “definite” by DC, and ● Group 4 includes 22 patients misclassified as “possible” IE by DC, all being “rejected” (n 5 21) or “possible” (n 5 1) by VRC
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#Diagnostic #Endocardite #Metabolomique #These
For the purpose of determining the sensitivity of VRC and DC in our series, only patients with “probable” IE by VRC and “definite” IE by DC were considered true IE. Patients with only “possible” or “rejected” IE by VRC and DC were considered false negative results for the diagnosis of IE.
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#Diagnostic #Endocardite #Metabolomique #These
Echocardiography was positive for IE in 87 among the 93 patients (93%), showing vegetations in 75 (81%) patients, abscesses in 16 (17%) patients, new periprosthetic regurgitation in 3 patients and aneurysm or perforation of the mitral valve in 8 patients
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#Diagnostic #Endocardite #Metabolomique #These
In six patients, echocardiography was not positive for IE, but in four patients, it was consistent with the diagnosis of IE, without meeting a major criterion.
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#Diagnostic #Endocardite #Metabolomique #These
Among the 18 patients without detectable vegetation, 12 had another major crite- rion (nine abscesses, three new periprosthetic regurgita- tions), 4 had only a minor echocardiographic criterion (valvular thickening or nonoscillating mass), 1 had a very small vegetation only detectable by surgical inspection and 1 had a negative initial TEE but developed vegetations on a repeat study
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#Diagnostic #Endocardite #Metabolomique #These
The sensitivity for the diagnosis of IE was better using DC than VRC (76% vs. 56%, respectively [p , 0.0001]).
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#Diagnostic #Endocardite #Metabolomique #These
In 32 cases the diagnosis of IE was rejected using VRC; in no case was this diagnosis rejected using DC (Table 2)
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#Diagnostic #Endocardite #Metabolomique #These
When the four patients with Q-fever endocarditis were excluded from the analysis, sen- sitivities of VRC and DC were 58% and 80%, respectively (p , 0.0001)
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#Diagnostic #Endocardite #Metabolomique #These
Among major criteria, positive BC were less frequently observed among patients with “possible” IE by DC (group 4) than in the other groups (p , 0.0001); the incidence of endocardiac involvement was not signifi- cantly different between groups (p 5 NS). Among minor criteria, fever (p 5 0.001) and vascular phenomena (p , 0.01) were less frequent among group 4 patients than in other groups.
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#Diagnostic #Endocardite #Metabolomique #These
In 11 patients (group 2), the diagnosis of IE was “rejected” by VRC, but “definite” by DC. The difference could be explained by negative BC and positive echocardio- grams in all patients. The cause of negative BC was prior antibiotic therapy in 7/11 patients.
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#Diagnostic #Endocardite #Metabolomique #These
In eight patients (group 3), the diagnosis of IE was “possible” by VRC but “definite” by DC. Blood cultures were positive in all patients, and echographic major criteria were present in six (75%) patients. Six patients met two major criteria in the Duke classification; two had one major and three minor criteria. The misclassification by VRC in these patients was essentially explained by the failure to consider echocardiographic abnormality as a major criteria
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#Diagnostic #Endocardite #Metabolomique #These
Twenty-two patients (group 4) were misclassified as possible IE using DC, being false negative in this classifi- cation; IE was “rejected” in all but one patient of this group using VRC; the diagnosis of IE was subsequently confirmed by pathology in all 22 patients.
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#Diagnostic #Endocardite #Metabolomique #These
One major and two minor criteria were present in 19/22 patients, not allowing the “definite” diagnosis of IE. Echo- cardiographic major criteria were present in 19 patients, but BC were negative in 21 patients. The cause for negative BC was prior antibiotic therapy in 11 patients and Q-fever endocarditis diagnosed by positive serology in three cases
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[unknown IMAGE 7074088094988]
[THÈSE] - Value and Limitations of the Duke Criteria for the Diagnosis of Infective Endocarditis.pdf
#Diagnostic #Endocardite #Metabolomique #These #has-images
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#Diagnostic #Endocardite #Metabolomique #These
Culture-negative IE was essentially observed among group 2 and group 4 patients. All 11 patients from group 2 and 21 of 22 group 4 patients had negative BC; the cause for negative BC was prior antibiotic therapy in 18 of these 33 patients; echocardiography was positive in 31 of them, showing vegetations in 21 cases, perivalvular abscesses in 8 cases and 2 aortic vegetations with associated mitral perforation
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#Diagnostic #Endocardite #Metabolomique #These
Echocardiographic pathologic lesions (vegetation or abscess) were confirmed by surgery and by histology showing active IE in all patients. Moreover, in 10 patients, a microorganism was subse- quently identified by culture or histology in a vegetation or an abscess, whereas preoperative BC were negative
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#Diagnostic #Endocardite #Metabolomique #These
Durack and colleagues (4) obtained a sensitivity of 80% in 69 pathologically confirmed cases of IE. This better sensitivity as compared with VRC was explained by the incorporation of both echocardio- graphic findings and knowledge of intravenous drug abuse into the clinical assessment (4). Similar results were inde- pendently obtained by Bayer et al. (3), and in the present study with a sensitivity of 76% for DC and 56% for VRC
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#Diagnostic #Endocardite #Metabolomique #These
The better sensitivity of DC is partly explained by the major incremental value of echocardiographic criteria, as already outlined by Dodds and Durack (8)
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#Diagnostic #Endocardite #Metabolomique #These
In our series, the sensitivity of echocardiogra- phy combining TTE and TEE was 93%, similar to other series of IE with pathologic confirmation (11,13).
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#Diagnostic #Endocardite #Metabolomique #These
Twenty-one of these 22 patients presented with negative BC. The main reason for negative BC in clinical practice is prior antibiotic therapy, a point emphasized by Cecchi et al. (21) that was observed in 11 of 22 group 4 patients in our series.
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#Diagnostic #Endocardite #Metabolomique #These
The second cause of culture-negative endocarditis in our series was Q-fever endocarditis.
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#Diagnostic #Endocardite #Metabolomique #These
Q fever is a worldwide zoonosis caused by Coxiella burnetii and is particularly frequent in France; we have previously shown (7) that the application of DC in 20 cases of pathologically proven Q-fever IE resulted in misclassification in 20% of patients as “possible” cases.
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#Diagnostic #Endocardite #Metabolomique #These
Finally, the ap- plication of DC for the diagnosis of IE has been shown to be of lower value in some patient groups, such as patients with prosthetic valves (23) and patients with IE affecting pacemaker leads (24).
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#Diagnostic #Endocardite #Metabolomique #These
In the recent series of Klug et al. (24), application of clinical DC allowed the diagnosis of “defi- nite” IE before leads cultures in only 25% and 59.3% of the patients in the acute and chronic groups, respectively. Thus, the authors proposed that other clinical criteria, such as local symptoms and pulmonary infections, could be added to conventional criteria in such patients. Fourteen patients in group 4 had either a prosthetic valve or a pacemaker lead IE.
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