Infective endocarditis (IE) is a rare but complex disease that is fatal if untreated. With a modern combination of antimicrobial therapy and heart valve surgery, mortality is still 10-20 %. The structure of the endocarditis vegetation impedes the penetration of phagocytic cells such as monocytes and granulocytes. This leads to high bacterial counts inside the vegetation and the need for long treatment courses with a combination of intravenously administered bactericidal antibiotics. The aim of this thesis was to study the changes in epidemiology, management, and mortality at our hospital between 1980 and 2001, and to identify prognostic factors associated with mortality. To assess the issue of referral bias, differences between referred episodes and episodes from our local community were studied. Additional aims were to study the occurrence of the pro-chemotactic cytokines IL-8 and TNF-α in heart valves and vegetations during the active phase of IE, and to study the effect of the glycopeptide antibiotic vancomycin in dense staphylococcal cultures in vitro. As it is a rare and complex disease, management of IE is usually complicated for non-specialists. For this reason a computerised decision support system for IE was developed and evaluated. Between 1980 and 2001, the occurrence of Staphylococcus aureus IE and the use of early heart valve surgery increased significantly, regardless of whether the episodes were referred or of local origin. Glycopeptide antibiotics, mainly vancomycin, were used more frequently, especially among referred patients. Referred patients were younger, predominantly male, had more complications, and received surgical treatment more often than patients from our local community. The reason for the lower frequency of female patients in the referral cohort cannot be explained by more comorbidity or fewer complications. The differences between referred and local episodes seen in our study highlight the need for assessment and adjustment for referral bias in IE studies (Paper I). In six patients who needed early heart valve surgery, the largest numbers of IL-8-containing cells, and the greatest amount of inflammation, were seen in patients with short preoperative antimicrobial treatment courses. No such relationships were seen with respect to TNF-α-containing cells. The IL-8-containing cells and the inflammatory cells were predominantly scattered in the heart valve stroma or in the margin of the vegetation (Paper II). The primary effect of IL-8 is to stimulate chemotaxis of polymorphonuclear neutrophil granulocytes. This indicates that there is no deficiency of IL-8 in the area close to the vegetation as a cause of the localised agranulocytosis often present inside the vegetation. Our study revealed a need for computerised decision support systems (DSSs) in the field of IE, but to be used in clinical practice these DSSs need be part of knowledge bases covering larger domains (Paper IV). Some of our initial ideas described in Paper III, especially the use of Internet technology and the combination of rule-based advice and explanatory hypertext, will probably be included in these knowledge bases. In vitro, there is a rapid reduction of free vancomycin in broth containing dense staphylococcal cultures. Consequently, there is a simultaneous increase in broth MICs, particularly in high inocula, which is not caused by a development of resistance (Paper V). These findings need further evaluation in vivo, but indicate that the dosing regimen of vancomycin is of particular importance in staphylococcal infections with dense inocula, e.g. infective endocarditis. Diabetes mellitus and moderate to severe heart failure were independent risk factors for 6-month mortality in left-sided, Duke definite IE episodes, regardless of referral or local origin of the episodes. Early heart valve surgery had a positive impact on the 6-month mortality in the referral cohort of episodes, which may be due to referral bias (Paper VI).

Systemic Lupus Erythematosus (SLE) is a multi-organ autoimmune disorder that may result in death due to cardiac dysfunction. This dysfunction often occurs due to an endocarditis, known as Libman-Sacks, which presents on heart valves. The condition is hard to clinically diagnose and is often observed postmortem. Heart damage has been observed in the NP-SLE Lewis rat model positive for SLE. However, research has not been done in this model on the correlation between SLE and Libman-Sacks endocarditis. Numbers of occurrence have ranged from 3-50% in SLE patients. The presence of Libman-Sacks endocarditis should likewise occur in 3-50% of NP-SLE Lewis rats. There will be seven NP-SLE Lewis rats, five negative serum control rats, and five saline injected control rats. By performing this controlled study in rats, the correlation between SLE and Libman-Sacks will be better understood. / Department of Physiology and Health Science

Streptococcus gordonii is a primary coloniser of the tooth surface where it efficiently ferments carbohydrates at pH levels above 6.0. By not being able to maintain the pH of dental plaque to a level required for enamel dissolution, the dominance of S. gordonii in dental plaque is considered a sign of a healthy oral cavity. However, upon entering the bloodstream and encountering a rise in pH, S. gordonii may become pathogenic, being one of the major causative organisms associated with infective endocarditis. Proteome analyses of S. gordonii grown at steady state in a chemostat allowed the phenotypic changes associated with alterations in pH levels characteristic of these two environments to be determined. As an initial starting point to this study, a two-dimensional electrophoresis (2- DE) reference map of S. gordonii grown at pH 7.0 was produced. Although only 50% of the S gordonii genome was available in an annotated form during the course of this study, the closely related Streptococcus pneumoniae genome (with which S. gordonii shares 97.24% DNA sequence homology) had been completed in 2001. The use of both of these databases allowed many of the S. gordonii proteins to be identified by mass spectrometry. Four hundred and seventy six protein spots, corresponding to 250 different proteins, or 12.5% of the S. gordonii proteome, were identified, giving rise to the first comprehensive proteome reference map of this oral bacterium. Of the 250 different proteins, 196 were of cellular origin while 68 were identified from the extracellular milieu. Only 14 proteins were common to both compartments. Of particular interest among the 54 uniquely identified extracellular proteins was a homologue of a peptidoglycan hydrolase that has been associated with virulence in S. pneumoniae. Among the other proteins identified were ones involved in transport and binding, energy metabolism, translation, transformation, stress response and virulence. Twelve cell envelope proteins were identified as well as 25 others that were predicted to have a membrane association based on the presence of at least one transmembrane domain. The study also confirmed the existence of 38 proteins previously designated as �hypothetical� or with no known function. Mass spectral data for over 1000 protein spots were accumulated and archived for future analysis when sequencing of the S. gordonii genome is finally completed. Following the mapping of the proteome of S. gordonii, alterations in protein spots associated with growth of the bacterium at pH intervals of 0.5 units in the pH range 5.5 - 7.5 were determined. Only 16 protein spots were shown to be significantly altered in their level of expression despite the range of pH studied. Among the differentially expressed proteins was a manganese-dependent inorganic pyrophosphatase (PpaC), which regulates expression of adhesins required for coaggregation. The expression of PpaC was highest at pH 6.5 - 7.0, the pH of a healthy oral cavity, indicating that PpaC may play an important part in dental plaque formation. Another differentially expressed protein was the heat-inducible transcription repressor (HrcA). Alterations in HrcA were consistent with its role as a negative repressor in regulating heat-shock proteins at low pH, even though no changes in the level of heat-shock proteins were observed as the pH declined. This result gave rise to the hypothesis that the possible reason cariogenic bacteria, such as Streptococcus mutans, can out compete S. gordonii at low pH might simply be due to their ability to manipulate their proteome in a complex manner for survival and persistence at low pH, unlike S. gordonii. This may imply some prevailing level of genetic regulation that is missing in S. gordonii.

Diss. (sammanfattning) Stockholm : Karol. inst. / Härtill 5 uppsatser.

Bakgrund Endokardit är dagsläget en relativt sällsynt infektionssjukdom som drabbar hjärtat och framförallt hjärtklaffarna. I Sverige drabbas årligen cirka 500 personer och överlevnaden med adekvat behandling ligger på cirka 80-90%. Endokardit är ett komplext sjukdomstillstånd med ofta kräver expertis från många olika specialister. Vårdtiden är lång och inte sällan med olika former av komplikationer som följd. Syftet med studien var att beskriva omvårdnaden av patienter med endokardit från ett sjuksköterskeperspektiv.Metoden som användes var en kvalitativ metod med beskrivande design. Intervjuer med strategiskt ändamålsurval som använt sig av inklusions- och exklusions kriterier har genomförts. Sex sjuksköterskor från olika bakgrund, kön och arbetsplatser deltog i studien. Datan som framkom analyserades genom manifest innehållsanalys med till viss del latenta inslag.Resultatet visar informanternas beskrivning av omvårdnad kring patienter med endokardit ur ett sjuksköterskeperspektiv. Detta ses i resultatets tre huvud kategorier: Patientens förutsättningar, organisationens förutsättningar, sjuksköterskans förutsättningar. Alla kategorierna påvisar hur komplex omvårdnad kring denna patientgrupp är utifrån ett sjuksköterskeperspektiv. Slutsats av studien visar att begreppet omvårdnad är ett svårtolkat begrepp även för erfarna sjuksköterskor. Patienter med ett tidigare missbruk är en speciellt sårbar grupp att hantera, där behöver arbetet ske med tanke på deras missbruk samtidigt som behandlingen av endokardit fortgår. Hur väl omvårdnadsmässigt infektionsavdelningar i Mellansverige tar hand om och behandlar patienter med endokardit beror till stor del på vilka resurser sjukhuset har samt hur stor erfarenhet de sjuksköterskor som arbetar där har av att vårda patienter med endokardit. / Background endocarditis is a relatively uncommon diagnosis compared to other infectious diseases. Endocarditis affects the heart muscle but is mainly situated in the heart valves. In Sweden today about 500 persons are affected annually, with adequate treatment and care the survival rate is high within 80-90% of all cases. Endocarditis is a complex disease that requires treatment and care from multiple specialists, the time spent in hospital is long compared to other diseases and is often prolonged by complications of the treatment.The Aim of the study was to describe the caring of patients with endocarditis from a nurse’s perspective.The method used was a qualitative analysis using descriptive design, with the use of strategic purposeful sampling with help of inclusion and exclusions criterias. Six Nurses from different backgrounds, genders and workplaces participated in the interview study. The data analysis was conducted using manifest content analysis with some grade of latent analysis included.The Result showed how the informants of the study described caring for patients with endocarditis from a nurses point of view. This is explained by the three major categories: Patients conditions, The Organisations prerequisite and the Nursing staffs experienced and educational level. They all tell about the complexity of caring for patients with endocarditis.The Conclusion of the study showed that Nursing care and the term caring itself are terms that are somewhat hard to grasp because of their wide meaning in the Nursing community. Patients with predeveloped addiction to some sort of drug is a special group of patients to handle, especially when they are infected by endocarditis. Since they have to be cared for in their addiction as well as their infection. How well nurses on infections wards in Sweden care for patients affected by endocarditis depends a lot on what other resources the hospital has and on the experienced level of the nurses working there.

Submitted by Maykon Nascimento (maykon.albani@hotmail.com) on 2016-05-09T19:10:21Z No. of bitstreams: 2 license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Dissertacao Grasiele Bonadiman.pdf: 3637833 bytes, checksum: 9c919dca44b71050b2c6cbe78d9a59a6 (MD5) / Approved for entry into archive by Patricia Barros (patricia.barros@ufes.br) on 2016-06-06T12:34:39Z (GMT) No. of bitstreams: 2 license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Dissertacao Grasiele Bonadiman.pdf: 3637833 bytes, checksum: 9c919dca44b71050b2c6cbe78d9a59a6 (MD5) / Made available in DSpace on 2016-06-06T12:34:39Z (GMT). No. of bitstreams: 2 license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Dissertacao Grasiele Bonadiman.pdf: 3637833 bytes, checksum: 9c919dca44b71050b2c6cbe78d9a59a6 (MD5) / Possíveis associações entre doença periodontal (DP) e alterações cardiovasculares em cães, como a endocardite infecciosa (EI), são relatadas na literatura, apesar de ainda não comprovadas. Fármacos anestésicos, utilizados para a tratamento periodontal (TP), podem levar à hipotensão, redução do fluxo sanguíneo coronariano e isquemia miocárdica. A determinação de biomarcadores, especialmente a troponina I cardíaca (TnIc), pode ser utilizada para a detecção de lesão miocárdica tanto em casos de EI, quanto por efeitos de fármacos anestésicos. Objetivou-se avaliar os níveis séricos de TnIc em cães com DP, como um indicador de EI, anestesiados para TP, com e sem o uso de antibióticos. Utilizou-se 24 cães com DP, sem evidências de outras doenças sistêmicas, selecionados por meio de avaliação física, laboratorial e cardiovascular. Formou-se três grupos de 8 cães cada: grupo I (controle) – cães anestesiados; grupo II - cães anestesiados submetidos a TP, não tratados com antibióticos; grupo III - cães anestesiados submetidos a TP, tratados com antibióticos. Os cães foram sedados com meperidina e acepromazina, induzidos com propofol e mantidos com isoflurano em oxigênio. Dosagens de TnIc foram realizadas imediatamente antes e 24 horas após o TP, com kit comercial pelo método de ELISA. A análise estatística foi realizada por meio do teste de "D'Agostino & Pearson", teste t para comparação de duas médias e teste post hoc de comparação múltipla de Tukey, após a análise de variância. Não houve diferença significativa nas dosagens de TnIc entre os grupos, nem entre os momentos avaliados (p>0,05). Conclui-se que não há aumento de TnIc em cães com DP após o TP, submetidos ou não a antibioticoterapia, podendo sugerir que não houve o desenvolvimento de EI; e não há aumento de TnIc em cães saudáveis submetidos ao protocolo anestésico estipulado. / Associations between periodontal disease (PD) and cardiovascular changes in dogs, such as infeccious endocarditis (IE), are reported by literature, although no evidences between them are verified. Anesthetic drugs, used for periodontal treatment (PT), can lead to hypotension, reduction of coronary blood flow and myocardial ischemia. Determination of biomarkers, especially cardiac troponin I (cTnI) can be used for the detection of myocardial injury in both cases: endocarditis and the effects of anesthetic drugs. This study aimed to evaluate canine cTnI in dogs with PD, as an indicator of IE, after PT, with and without using antibiotics. It was used 24 dogs with PD, with no evidence of any other systemic diseases. They were selected by physical examination, laboratory and cardiovascular evaluation and were divided into three groups: group I (n=8; control) - anesthetized dogs, group II (n=8) - anesthetized dogs submited to PT, not treated with antibiotics, group III (n=8) - anesthetized dogs submited to PT, treated with antibiotics. The dogs were sedated with acepromazine and meperidine, induced with propofol and maintained with isoflurane in oxygen. Canine cTnI dosages were taken immediately before and 24 hours after PT, using commercial kit (ELISA). Statistical analysis were performed by using "D'Agostino & Pearson" normality test, unpaired t test to compare two samples and Tukey´s post hoc test for multiple comparisons. All tests were performed at a level of significance of 0.05 No significant differences were found between groups or in different moments (p>0.05). It was concluded that there is no increased cTnI in dogs with PD after PT, treated or not with antibiotics, suggesting that there was no development of IE, and there is no increase in canine cTnI in healthy dogs anesthetized using this protocol.

Orientador: Renata de Oliveira Mattos-Graner / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba / Made available in DSpace on 2018-08-19T14:43:07Z (GMT). No. of bitstreams: 1 Moraes_JuliannaJoannadeCarvalho_D.pdf: 2742487 bytes, checksum: fd22472bad0fcb9906c477e4e103b797 (MD5) Previous issue date: 2011 / Resumo: Streptococcus sanguinis são colonizadores primários dos dentes reconhecidos como microrganismos comensais benéficos da cavidade bucal, pois são capazes de inibir o crescimento de espécies patogênicas, como Streptococcus mutans. S. sanguinis são comumente envolvidos em endocardite bacteriana, embora por mecanismos de patogenicidade ainda não conhecidos. Para colonizar os dentes ou tecidos cardíacos, S. sanguinis devem ser capazes de se estabelecer em biofilmes e de se adaptar às diversas condições de estresse ambiental decorridas da ação de microrganismos competidores e/ou das defesas do hospedeiro. A resposta bacteriana a condições de estresse ambiental é regulada por sistemas reguladores globais de transcrição de dois componentes (SDC), os quais são essenciais para modular o transcriptoma bacteriano durante os processos de colonização e infecção do hospedeiro. O genoma de S. sanguinis SK36 apresenta 14 desses sistemas. Através de análises de BLAST, identificou-se um SDC com alta similaridade ao sistema VicRK (vic de virulence control), o qual regula fatores de virulência e é conservado em diversas espécies de bactérias Gram-positivas, como S. mutans e Streptococcus pneumoniae. O objetivo deste trabalho foi caracterizar a função do sistema VicRK na biologia de S. sanguinis, através da análise dos efeitos da inativação de vicK em diversas características bacterianas possivelmente associadas à virulência e à formação de biofilmes. Para isto, foi construído um mutante knock-out do gene vicK a partir da cepa SK36, o qual foi designado SKvicK. SKvicK foi comparado à cepa selvagem quanto à capacidade de formação de biofilmes e quanto às características que influenciam na capacidade de colonização (hidrofobicidade, atividade autolítica e sensibilidade ao estresse oxidativo) em diferentes condições atmosféricas. Também foram comparados, entre as cepas, os padrões de expressão de genes com possível função de virulência, cujos ortólogos são regulados por VicRK nas espécies S. mutans e/ou S. pneumoniae. Estes incluem genes relacionados à formação de biofilmes e biogênese da parede celular (ssapcsB, lysM, gtfP), à resposta ao estresse oxidativo e produção de peróxido de hidrogênio (sodA, spxB, ccpA). A inativação de vicK inibiu claramente a formação inicial de biofilmes. Além disto, SKvicK demonstrou maior sensibilidade ao estresse oxidativo e maior hidrofobicidade celular. A inativação de vicK também inibiu, de forma significativa, a transcrição dos genes pcsB, lysM, spxB e comE. Estes dados indicam que VicRK regula diversas funções biológicas de S. sanguinis importantes para a colonização de humanos / Abstract: Streptococcus sanguinis are primary colonizers of the teeth and recognized as beneficial commensal microorganisms of the oral cavity because they are able to inhibit the growth of pathogenic species such as Streptococcus mutans. S. sanguinis are commonly involved in the infective endocarditis, although pathogenic mechanisms are still unknown. S. sanguinis are able to establish in biofilms and to adapt among various environmental stress conditions from competing microorganisms and/or from host defenses during colonization of enamel or endothelial tissues. Bacterial responses from environmental stress conditions are regulated by two-component global regulatory systems (TCS), which are essential to modulate the bacterial transcriptome during colonization and infection of the host. S. sanguinis SK36 genome contains at least 14 TCS. Through BLAST analyses, we identified a TCS with high similarity to VicRK system (vic from virulence control), which regulates virulence factors and is conserved in several species of gram-positive bacteria such as S. mutans and Streptococcus pneumoniae. The aim of this study was to characterize the role of VicRK system in S. sanguinis biology, by analyzing the effects of vicK inativation on several characteristics potentially associated with bacterial virulence and biofilm formation. For this purpose, vicK mutant gene knock-out was obtained from strain SK36 and it was designated SKvicK. SKvicK was compared to the wild-type strain about the ability to form biofilms and cellular traits which influence in the ability of host colonization (hydrophobicity, autolytic activity and sensitivity to oxidative stress) under diverse atmospheric conditions. Gene expression was also compared in the strains because these genes are potencially involved in virulence, whose orthologs are regulated by VicRK system in S. mutans and S. pneumoniae species. These include genes involved in biofilm formation and cell wall biogenesis (ssapcsB, lysM, gtfP), oxidative stress response and production of hydrogen peroxide (sodA, spxB, ccpA). The inactivation of vicK inhibited the initial formation of biofilms. Moreover, SKvicK showed increased sensitivity to oxidative stress and cell hydrophobicity. vicK gene inativation also signicantly down-regulated transcription of pcsB, lysM, spxB and comE. These data indicate that VicRK regulates several biological functions relevant for S. sanguinis colonization / Doutorado / Estomatologia / Doutor em Estomatopatologia

Manganese-deficient Streptococcus sanguinis mutants exhibit a dramatic decrease in virulence for infective endocarditis and in aerobic growth in manganese-limited media. Loss of activity of a manganese-dependent, oxygen-dependent ribonucleotide reductase (RNR) could explain the decrease in virulence. When the genes encoding this RNR are deleted, there is no growth of the mutant in aerobic broth culture or in an animal model. Testing the contribution of the aerobic RNR to the phenotype of a manganese transporter mutant, a heterologous class II RNR from Lactobacillus leichmannii called NrdJ that requires B12 rather than manganese as a cofactor was previously introduced into an RNR mutant of S. sanguinis. Aerobic growth was only partially restored. Currently, we sought to improve NrdJ-dependent growth by (i) amending the medium to increase cellular levels of B12; (ii) characterizing a spontaneous mutant of the NrdJ-complemented strain with improved aerobic growth; and (iii) altering this strain through further genetic manipulation.

L’endocardite infectieuse (EI) est une maladie rare, de diagnostic difficile et de pronostic réservé. Staphylococcus aureus (SA) et les streptocoques oraux en sont les principaux microorganismes responsables. L’évaluation du risque de survenue de l’EI et l’amélioration des connaissances justifiant la stratégie de prévention nécessitent la mise en place de grandes cohortes cliniques et l’utilisation de bases médico-administratives. Chez les 2 008 patients (pts) présentant une bactériémie à SA de la cohorte multicentrique nationale VIRSTA, nous avons développé et validé un score prédictif d’EI comportant les caractéristiques initiales des pts et celles initiales et évolutives de la bactériémie. Les pts dont le score était ≤ 2 avaient un très faible risque d’EI (1% ; valeur prédictive négative [IC95%] = 99% [98;99]) comparés à ceux dont le score était ≥ 3, à risque d’EI élevé (17%) pour lesquels une échocardiographie devrait être effectuée. Utilisant la base médico-administrative du SNIIRAM, nous avons évalué la relation entre la pratique de gestes buccodentaires invasifs (GBDI) et la survenue d’EI à streptocoques oraux à partir d’une cohorte de 138 876 porteurs de prothèses valvulaires cardiaques ainsi que d’un plan expérimental de type case-crossover incluant 648 EI à streptocoques oraux. L’incidence d’EI à streptocoques oraux [IC95%] était de 93,7 pour 100 000 PA [82,4;104,9] sans augmentation significative du risque dans les 3 mois suivant un GBDI (RR= 1,25 [0,82;1,82]). Dans l’analyse case-crossover, la fréquence d’exposition à un GBDI dans les 3 mois précédent l’EI était faible mais plus élevée que lors de périodes contrôles antérieures (5,1% vs 3,2% ; OR : 1,66 [1,05;2,63]). Les GBDI pourraient contribuer au développement des EI à streptocoques oraux dans la population de pts porteurs de prothèses valvulaires cardiaques.La qualité des données de VIRSTA associée à la puissance du SNIIRAM ont permis l’identification des pts à risque d’EI à SA et la clarification de la contribution des GBDI dans les EI à streptocoques oraux. / Infective endocarditis (IE) is a rare disease, difficult to diagnose, with high morbidity and mortality rates. Main involved microorganisms are Staphylococcus aureus and oral streptococci. Clinical research to improve IE risk assessment and IE prevention strategy requires the establishment of large clinical cohort studies and the use of medico-administrative databases. Using data from the multicenter French prospective VIRSTA cohort study on 2 008 adult patients (pts) with Staphylococcus aureus bloodstream infection (SAB), we have developed and validated an IE prediction score taking into account pts’ background and initial SAB characteristics. Pts with a score ≤ 2 had a very low risk of IE (1%, negative predictive value [95% CI] = 99% [98;99]) compared to those with a score ≥ 3, at higher risk of IE (17%) for whom an echocardiography is needed. Using the medico-administrative SNIIRAM database, we assessed the relation between invasive dental procedures (IDP) and oral streptococcal IE in a population-based cohort study of 138 876 pts with prosthetic heart valves and a case-crossover study including 648 pts with oral streptococcal IE. Incidence rate of oral streptococcal IE [95% CI] was 93.7 per 100 000 PA [82.4;104.9] without significant increase within the 3 months following IDP (RR = 1.25 [0.82;1.82]). In the case-crossover analysis, exposure to IDP was more frequent in the 3 months preceding IE than during previous control periods (5.1% vs. 3.2%, OR: 1.66 [1.05;2.63]). IDP may contribute to the development of oral streptococcal IE in pts with prosthetic heart valves.The quality of data from VIRSTA study combined with the power of SNIIRAM database made possible the identification of IE at-risk SAB pts and the evaluation of the IDP contribution in oral streptococcal IE.

Elizabethkingia Meningoseptica (E. Meningoseptica) an oxidase-positive gram-negative aerobic rod.1-2 Although ubiquitous in nature and widely distributed in soil and water, it is not a part of normal human flora. Cases of outbreaks of meningitis in premature neonates or infants have been reported, however, very few cases have been reported in adults.3 Infection is primarily nosocomial, or hospital acquired and has been implicated in bacteremia, meningitis, pneumonia, endocarditis especially in immunocompromised individuals.2-4 We report a 29-year-old male with past medical history significant for intravenous drug abuse, hepatitis C, oxymorphone induced hemolytic uremic syndrome, who presented to hospital with altered mental status. On admission, patient was unresponsive to vocal commands, febrile (102.3 F), tachycardic and tachypneic. He had pinpoint pupils and diffuse petechiae. In addition, he had erythematous flat macular lesions on his palms and dorsum of hands as well as injection marks in left cubital fossa. Cardiac examination was significant for a grade III systolic murmur at apical region and diastolic murmur at left second intercostal space. Laboratory studies revealed thrombocytopenia (43,000m/microL), lactic acidosis (4.9mmol/L), serum creatinine (Cr) of 6.6 mg/dL, glomerular filtration rate (GFR) of 10 ml/min. Transthoracic echocardiogram (TTE) revealed large mobile vegetation on aortic valve measuring 3.6 x 0.72 cm. Patient’s presentation was consistent with infective endocarditis with the vegetation seen on TTE and patient’s physical findings. Magnetic Resonance Imaging of the brain showed numerous small hemorrhagic infarcts, likely secondary to emboli from aortic valve vegetation. Patient required intubation for airway protection and started on hemodialysis. He was initially started on Meropenem and Vancomycin for infective endocarditis and later switched to Ciprofloxacin based on blood cultures and sensitivities which revealed methicillin sensitive staphylococcus aureus and multi-drug resistant E. Meningoseptica. Patient was transferred to long term care facility after acute care at the hospital. The increasing incidence of polymicrobial infective endocarditis and increasing resistance to antibiotic therapy pose challenges to the rapid assessment and treatment to mitigate the multi-organ involvement with septic emboli. Reports of pathogenicity associated with native valve endocarditis with this organism is scarce and exist primarily in a very few case reports and is resistant to many traditional antibiotics.5,6 E. Meningoseptica has shown antimicrobial susceptibility to the newer quinolones, rifampin, trimethoprim/sulfamethoxazole and ciprofloxacin with reasonable activity.7 Due to the unusual pattern of antibiotic resistance, early switching to appropriate antibiotics based on sensitivities is crucial for survival in patients with E. Meningoseptica. References 1..Kim KK, Kim MK, Lim JH, Park HY, Lee ST. Transfer of Chryseobacterium meningosepticum and Chryseobacterium miricola to Elizabethkingia gen. nov. as Elizabethkingia meningoseptica comb. nov. and Elizabethkingia miricola comb. nov. Int J Syst Evol Microbiol.2005 May;55(Pt 3):1287-93. 2:Shinha T, Ahuja R. Bacteremia due to Elizabethkingia meningoseptica. IDCases. 2015 Jan 17;2(1):13-5. doi: 10.1016/j.idcr.2015.01.002. eCollection 2015. 3..Jung SH, Lee B, Mirrakhimov AE, Hussain N. Septic shock caused by Elizabethkingia meningoseptica: a case report and review of literature. BMJ Case Rep. 2013 Apr 3;2013. pii: bcr2013009066. doi: 10.1136/bcr-2013-009066. 4.Ratnamani MS, Rao R. Elizabethkingia meningoseptica: Emerging nosocomial pathogen in bedside hemodialysis patients. Indian J Crit Care Med. 2013 Sep;17(5):304-7. 5.Bomb K, Arora A, Trehan N. Endocarditis due to Chryseobacterium meningosepticum. Indian J Med Microbiol. 2007 Apr;25(2):161-2. 6.Yang J, Xue W, Yu X. Elizabethkingia meningosepticum endocarditis: A rare case and special therapy. Anatol J Cardiol. 2015 May;15(5):427-8. 7. Hsu MS, Liao CH, Huang YT, Liu CY, Yang CJ, Kao KL, Hsueh PR. Clinical features, antimicrobial susceptibilities, and outcomes of Elizabethkingia meningoseptica (Chryseobacterium meningosepticum) bacteremia at a medical center in Taiwan,1999-2006. Eur J Clin Microbiol Infect Dis. 2011 Oct;30(10):1271-8.