Thesis (M.S.)--University of Michigan, 1976.

BACKGROUND: Infective endocarditis (IE) is an infectious disease, most often bacterial in etiology, which affects the endocardial tissue layer of the heart. Despite advances in diagnostic technology, surgical technique, and antimicrobial therapy, IE remains a high-mortality disease. OBJECTIVE: This is a proposed quality improvement initiative for the Boston Medical Center (BMC) inpatient medicine service. The initiative aims to identify predictors of mortality in patients with IE, and then use the predictors to create a mortality risk-assessment checklist. The checklist will serve as a clinical tool for medicine service providers to help determine if upgrade to ICU level of care is warranted. With early upgrade to an ICU setting, patients with a high risk of mortality will receive more individualized care and expedited medical intervention. The goal of this quality improvement initiative is to decrease mortality rate in patients with IE at BMC. METHODS: This quality improvement initiative will implement the PDSA (plan, do, study, act) model for quality improvement. The checklist will be integrated into the electronic health record system at BMC and will be implemented over a two-year time period. Each PDSA cycle will last one year, and between PDSA cycles the checklist will be modified according to medical provider feedback. The data will be gathered through chart reviews to determine pre and post-checklist differences in number of transfers to the ICU and overall mortality rates of IE patients at BMC. RESULTS: The literature review of this proposed quality improvement initiative has identified nine independent risk factors for mortality in patients with IE: Staphylococcus aureus as infective organism, New York Heart Association class IV heart failure, left ventricular ejection fraction < 40%, vegetation size ≥ 15 mm, age > 50 years, diabetes mellitus, peripheral dermatologic findings on physical examination, serum neutrophil-to-lymphocyte ratio > 5.45, and serum D-dimer level > 4.0 mg/L. CONCLUSION: If medical providers had access to a risk assessment tool to help identify IE patients with a high risk of mortality, they could more accurately determine appropriate level of care, expedite medical intervention, and possibly reduce rates of in-hospital death in patients with IE.

Objective: Following the incidental multicenter study of Endocarditis 2007 check the quality of microbiological diagnosis of infective endocarditis (IE) in the Czech Republic. Material and Methods: Prospective multicenter study of Endocarditis 2007 examined the incidence and characteristics of infective endocarditis for 12 months (February 1, 2007 to January 31, 2008) in 29 hospitals in the country. Mandates doctors sent to the Prague Centre report all cases of IE in a pre-defined catchment area of their hospitals. Was used for reporting standard form, data about patients were anonymous. There were collected 132 reports of IE. My own work consisted in re-processing and verification of data on etiology and diagnosis of IE. The basis of retrospective telephone inquiries were directed to the appropriate microbiological department, with particular emphasis on the actual number of blood cultures for individual patients, and culture findings. After comparing data with data received reports from microbiology laboratories was corrected any incorrect information. So the results were validated by the study. At the same time to assess the quality of the interpretation of microbiological findings of clinicians. Conclusion: Previous use of antibiotics reduces the probability of detection of pathogens. This relationship...

Aortic dissection is a life-threatening emergency associated with significant mortality rate. Early diagnosis is essential to improve the survival. Although the most common presentation is severe chest pain, it can be variable leading to delay in the diagnosis especially if it is painless. Painless aortic dissection is a rare entity with sparse data available based on case reports. We present a case of a young male with an atypical presentation where the presumptive diagnosis of infective endocarditis was made based on initial presentation but was eventually diagnosed as painless aortic dissection.

In the setting of an increasing incidence of endocarditis in the United States, we report a patient with necrotizing crescentic glomerulonephritis (GN) associated with native valve bacterial endocarditis due to Streptococcus parasanguinis. He was started on appropriate antibiotic treatment and subsequent blood cultures showed no growth. However, due to continuing decline in kidney function, immunosuppressive therapy was started. Despite immunosuppressive therapy and antibiotics, renal function did not improve and chronic hemodialysis was required. Due to rarity of condition, there are no definite treatment guidelines available. Antibiotics, steroids, immunosuppressive agents can be of help in most cases. Further research in this regard may help with early diagnosis and better treatment modalities.

Streptococcus sanguinis is the second most common causative agent of bacterial infective endocarditis (IE). Risk of S. sanguinis IE is dependent on pre-disposing damage to the heart valve endothelium, which results in deposition of clotting factors for formation of a sterile thrombus (referred to as vegetation). Despite medical advances, high mortality and morbidity rates persist. Molecular characterization of S. sanguinis virulence determinants may enable development of prevention methods. In a previous screen for S. sanguinis virulence determinants by signature-tagged mutagenesis (STM) an attenuated mutant was identified with a transposon insertion in the nrdD gene, encoding an anaerobic ribonucleotide reductase. Evaluation of this mutant, as well as an nrdD in-frame deletion mutant, JFP27, by a soft-agar growth assay confirmed the anaerobic growth sensitivity of these strains. These studies suggest that an oxygen gradient occurs at the site of infection which selects for expression of anaerobic-specific genes at the nexus of the vegetation. The random STM screen failed to identify any favorable streptococcal surface-exposed prophylactic candidates. It was also apparent that additional genetic tools were required to facilitate the in vivo analyses of mutant strains. As it was desirable to insert antibiotic resistance markers into the chromosome, we identified a chromosomal site for ectopic expression of foreign genes. In vitro and in vivo analyses verified that insertion into this site did not affect important cellular phenotypes. The genetic tools developed facilitated further in vivo screening of S. sanguinis cell wall-associated (Cwa) protein mutants. A directed application of STM was employed for a comprehensive analysis of this surface protein class in the rabbit model of IE. Putative sortases, upon which Cwa proteins are dependent for cell surface localization, were also evaluated. No single S. sanguinis Cwa protein was determined essential for IE by STM screening; however competitiveness for colonization of the infection site was reduced for the mutant lacking expression of sortase A. The studies described here present a progressive picture of S. sanguinis IE, beginning with surface protein-dependent colonization of the vegetation in early IE, that later shifts to a bacterial persistence in situ dependent on condition-specific housekeeping genes, including nrdD.

Staphylococcus aureus is defined by its ability to agglutinate during exposure to human blood plasma. Although agglutination has long correlated with disease severity, the function of agglutination during infection remains unclear. Increasing evidence suggests the mechanisms of agglutination are highly complex and poorly understood. The goal of this dissertation was to characterize the mechanisms required for S. aureus agglutination in vitro and determine how these factors contribute to pathogenesis. Chapter II focuses on the development of two in vitro agglutination assays, which allow the process to be measured quantitatively. Through these assays, we confirmed the major factors contributing to agglutination are human fibrinogen and the bacterial surface protein, ClfA. Productive interactions between these two factors are required for agglutination to proceed. Surprisingly, we also identified a novel regulatory system that significantly contributed to agglutination. Inactivation of the ArlRS two-component system (TCS) prevents agglutination in both of the developed assays. Studies in Chapter III focused on characterizing the mechanism by which ArlRS inhibits agglutination. To examine regulation, quantitative PCR identified the major output of the ArlRS system as the gene ebh. Surprisingly, transcript levels of known extracellular matrix (ECM) binding proteins did not change. Characterization of ebh indicated that overexpression in an arlRS mutant is the major factor responsible for preventing agglutination. Deletion of ebh restores the ability of the arlRS mutant to agglutinate in both gravity and flow-based agglutination assays. Fluorescence microscopy of clumps indicates wildtype cells bind and incorporate fluorescently labeled human fibrinogen (Fg) displaying co-localization with the clumps. Surprisingly, arlRS mutants also bound human Fg, but these interactions were not productive for clumping, suggesting successful agglutination is more complex than binding ECM proteins. These studies indicate that ArlRS regulates agglutination through a unique mechanism that depends on the surface protein Ebh. Studies in Chapter IV were performed to determine the role ArlRS played in pathogenesis. A rabbit model of infective endocarditis and sepsis was employed to assess ArlRS virulence because this model has been shown to require agglutination for disease progression. Mutants in arlRS displayed reduced virulence in the rabbit model of infective endocarditis, which correlated with the mutant's inability to form a vegetation of the heart valve. These studies provide further insight into the importance of S. aureus agglutination during infection and define a mechanism of regulation through a novel surface protein.

Staphylococcus aureus is a gram positive bacterium asymptomatically colonizing 30-40% of the human population. S. aureus causes a variety of infections including superficial skin lesions, toxic shock syndrome, and infective endocarditis (IE). There are 100,000 cases of IE each year in the United States. IE is a life threatening infection of native/prosthetic valves and the lining of the heart. It is characterized by the formation of vegetations, “cauliflower-like” structures composed of bacteria and host factors. S. aureus is the most commonly identified pathogen (up to 40%) in patients with IE. USA200 (Clonal Complex 30) strains of S. aureus are significantly associated with IE, all of which produce toxic shock syndrome toxin-1 (TSST-1) and β-toxin. TSST-1 characterizes the staphylococcal Group I superantigens (SAgs). The major mechanism of activity of TSST-1 and other SAgs is the ability to activate T-cells and APCs by non-specifically cross-bridging Vβ-chains of T-cell receptors (TCRs) with α and/or β-chains of major histocompatibility complex II (MHCII) molecules on antigen presenting cells (APCs). In a rabbit model of IE and sepsis, TSST-1 is critical for the development of vegetations and the associated colony forming units (CFUs). β-toxin has a molecular mass of 35 kDa, a basic pI (>10.0), and is a member of the DNase I superfamily. This cytotoxin has two distinct mechanisms of action: sphingomyelinase (SMase) activity and DNA biofilm ligase activity. β-toxin is critical for causing IE in a rabbit model that strongly resembles human disease. This toxin association had been observed, but studies have not been completed to determine what role TSST-1 and β-toxin play independently and in cooperation with one another, and more specifically which mechanism each uses, during IE infections. While TSST-1 and β-toxin are both important for IE, they are very different toxins. My studies determined that the presence of TSST-1 and β-toxin in combination results in the highest levels of lethality in a rabbit model of IE. A strain expressing TSST-1 lacking superantigenic activity has decreased lethality compared to the same strain expressing wild type TSST-1. My study is the first to begin characterization of the DNA biofilm ligase active site by identifying important residues via a DNA binding and biofilm formation assays. Furthermore, my research shows that a β-toxin mutant lacking SMase activity is decreased in lethality and vegetation formation compared to wild type. β-toxin mutants disrupted in biofilm ligase activity do not decrease lethality but are deficient in vegetation formation compared to wild type. Utilizing in vitro assays to assess cellular events during IE, I established that β-toxin causes changes to morphology and is cytotoxic to human aortic endothelial cells (HAECs), inhibits production of IL-8, and modulates the expression levels of cluster of differentiation 40 (CD40) and vascular cell adhesion molecule 1 (VCAM-1). My work shows these two virulence factors (TSST-1 and β-toxin) produced by USA200 strains and other clonal groups play important roles in causing IE.

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.

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).