Prevalence of Infective Endocarditis in Streptococcal Bloodstream Infections Is Dependent on Streptococcal Species

Supplemental Digital Content is available in the text. Background: Streptococci frequently cause infective endocarditis (IE), yet the prevalence of IE in patients with bloodstream infections (BSIs) caused by different streptococcal species is unknown. We aimed to investigate the prevalence of IE at species level in patients with streptococcal BSIs. Methods: We investigated all patients with streptococcal BSIs, from 2008 to 2017, in the Capital Region of Denmark. Data were crosslinked with Danish nationwide registries for identification of concomitant hospitalization with IE. In a multivariable logistic regression analysis, we investigated the risk of IE according to streptococcal species adjusted for age, sex, ≥3 positive blood culture bottles, native valve disease, prosthetic valve, previous IE, and cardiac device. Results: Among 6506 cases with streptococcal BSIs (mean age 68.1 years [SD 16.2], 52.8% men) the IE prevalence was 7.1% (95% CI, 6.5–7.8). The lowest IE prevalence was found with Streptococcus pneumoniae (S pneumoniae) 1.2% (0.8–1.6) and Spyogenes 1.9% (0.9–3.3). An intermediary IE prevalence was found with Sanginosus 4.8% (3.0–7.3), Ssalivarius 5.8% (2.9–10.1), and Sagalactiae 9.1% (6.6–12.1). The highest IE prevalence was found with Smitis/oralis 19.4% (15.6–23.5), Sgallolyticus (formerly Sbovis) 30.2% (24.3–36.7), Ssanguinis 34.6% (26.6–43.3), Sgordonii 44.2% (34.0–54.8), and Smutans 47.9% (33.3–62.8). In multivariable analysis using S pneumoniae as reference, all species except S pyogenes were associated with significantly higher IE risk, with the highest risk found with S gallolyticus odds ratio (OR) 31.0 (18.8–51.1), S mitis/oralis OR 31.6 (19.8–50.5), S sanguinis OR 59.1 (32.6–107), S gordonii OR 80.8 (43.9–149), and S mutans OR 81.3 (37.6–176). Conclusions: The prevalence of IE in streptococcal BSIs is species dependent with S mutans, S gordonii, S sanguinis, S gallolyticus, and S mitis/oralis having the highest IE prevalence and the highest associated IE risk after adjusting for IE risk factors.

[1]  H. Bundgaard,et al.  External validation of the HANDOC score – high sensitivity to identify patients with non-beta-haemolytic streptococcal endocarditis , 2019, Infectious diseases.

[2]  O. Alfieri,et al.  Clinical presentation, aetiology and outcome of infective endocarditis. Results of the ESC-EORP EURO-ENDO (European infective endocarditis) registry: a prospective cohort study. , 2019, European heart journal.

[3]  L. Køber,et al.  Prevalence of infective endocarditis in patients with positive blood cultures: a Danish nationwide study. , 2019, European heart journal.

[4]  K. Iversen,et al.  Prevalence of Infective Endocarditis in Enterococcus faecalis Bacteremia. , 2019, Journal of the American College of Cardiology.

[5]  N. Ghanem-Zoubi,et al.  Portraying infective endocarditis: results of multinational ID-IRI study , 2019, European Journal of Clinical Microbiology & Infectious Diseases.

[6]  S. Gordon,et al.  Distribution of streptococcal groups causing infective endocarditis: a descriptive study. , 2018, Diagnostic microbiology and infectious disease.

[7]  L. Pedersen,et al.  Positive predictive value of infective endocarditis in the Danish National Patient Registry: a validation study , 2018, Epidemiology and Infection.

[8]  M. Rasmussen,et al.  HANDOC: A Handy Score to Determine the Need for Echocardiography in Non-&bgr;-Hemolytic Streptococcal Bacteremia , 2018, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[9]  T. Marrie,et al.  Risk factors for pneumococcal endocarditis , 2018, European Journal of Clinical Microbiology & Infectious Diseases.

[10]  José Luis Bernal,et al.  The Evolving Nature of Infective Endocarditis in Spain: A Population-Based Study (2003 to 2014). , 2017, Journal of the American College of Cardiology.

[11]  H. Bøtker,et al.  Positive predictive value of cardiovascular diagnoses in the Danish National Patient Registry: a validation study , 2016, BMJ Open.

[12]  P. Søgaard,et al.  Risk Factors of Endocarditis in Patients With Enterococcus faecalis Bacteremia: External Validation of the NOVA Score. , 2016, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[13]  L. Olaison,et al.  Clinical presentation of infective endocarditis caused by different groups of non-beta haemolytic streptococci , 2015, European Journal of Clinical Microbiology & Infectious Diseases.

[14]  Susanna Price,et al.  2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). , 2015, European heart journal.

[15]  Sigrun Alba Johannesdottir Schmidt,et al.  The Danish National Patient Registry: a review of content, data quality, and research potential , 2015, Clinical epidemiology.

[16]  A. Bolger,et al.  Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association , 2015, Circulation.

[17]  J. Miro,et al.  Characteristics and Outcome of Streptococcus pneumoniae Endocarditis in the XXI Century , 2015, Medicine.

[18]  E. Hess,et al.  Predicting Risk of Endocarditis Using a Clinical Tool (PREDICT): Scoring System to Guide Use of Echocardiography in the Management of Staphylococcus aureus Bacteremia. , 2015, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[19]  J. Mehta,et al.  Trends in infective endocarditis incidence, microbiology, and valve replacement in the United States from 2000 to 2011. , 2015, Journal of the American College of Cardiology.

[20]  F. Fernández‐Avilés,et al.  The NOVA score: a proposal to reduce the need for transesophageal echocardiography in patients with enterococcal bacteremia. , 2015, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[21]  Henrik Toft Sørensen,et al.  The Danish Civil Registration System as a tool in epidemiology , 2014, European Journal of Epidemiology.

[22]  J. Hallas,et al.  The Danish National Prescription Registry , 2011, Scandinavian journal of public health.

[23]  V. Fowler,et al.  Prevalence of infective endocarditis in patients with Staphylococcus aureus bacteraemia: the value of screening with echocardiography. , 2011, European journal of echocardiography : the journal of the Working Group on Echocardiography of the European Society of Cardiology.

[24]  C. Doern,et al.  It's Not Easy Being Green: the Viridans Group Streptococci, with a Focus on Pediatric Clinical Manifestations , 2010, Journal of Clinical Microbiology.

[25]  G Greub,et al.  Performance of Matrix-Assisted Laser Desorption Ionization-Time of Flight Mass Spectrometry for Identification of Bacterial Strains Routinely Isolated in a Clinical Microbiology Laboratory , 2010, Journal of Clinical Microbiology.

[26]  M. Kilian,et al.  Use of Phylogenetic and Phenotypic Analyses To Identify Nonhemolytic Streptococci Isolated from Bacteremic Patients , 2005, Journal of Clinical Microbiology.

[27]  R. Facklam,et al.  What Happened to the Streptococci: Overview of Taxonomic and Nomenclature Changes , 2002, Clinical Microbiology Reviews.

[28]  V. Fowler,et al.  Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. , 2000, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[29]  T. F. Andersen,et al.  The Danish National Hospital Register. A valuable source of data for modern health sciences. , 1999, Danish medical bulletin.