Infective endocarditis (IE) remains a major clinical problem, with mortality rates of 20% to 40%. [1][2][3] During the active course of IE, neurological complications occur in 20% to 40% of patients 1,4,5 and have been linked to a poorer outcome. 1,2,5,6 In several of the related reports, however, neurological complication is a generic term referring to a broad spectrum of complications ranging from nonspecific manifestations, such as nonfocal encephalopathy, seizures, or headache, to stroke or severe cerebral hemorrhage. 4,7 This all-inclusive approach can lead to confusion when investigating the true effect of brain involvement on the outcome of IE or the relationships between brain injury and certain characteristics Background-The purpose of this study was to assess the incidence of neurological complications in patients with infective endocarditis, the risk factors for their development, their influence on the clinical outcome, and the impact of cardiac surgery. Antimicrobial treatment reduced (by 33% to 75%) the risk of neurological complications. In patients with hemorrhage, mortality was higher when surgery was performed within 4 weeks of the hemorrhagic event (75% versus 40% in later surgery). Conclusions-Moderate to severe ischemic stroke and brain hemorrhage were found to have a significant negative impact on the outcome of infective endocarditis. Early appropriate antimicrobial treatment is critical, and transitory discontinuation of anticoagulant therapy should be considered. Methods and Results-This García-Cabrera et al Endocarditis, Neurological Complications 2273of IE (eg, vegetation size or affected valve). Another debated point requiring clarification is whether brain damage may worsen after valve surgery in patients experiencing these complications. Several of the previous studies investigating these and other issues have the limitations of retrospective data collection, 8,9 referral center bias, 8,10 or analysis of too few events to obtain valid conclusions. 4,8 Clinical Perspective on p 2284The objectives of the present study were to assess the incidence of neurological complications in IE patients, the risk factors for their development, the associated risk of death, and the influence of valve surgery in this situation on patient outcome. Methods Study Design and PatientsThe study included patients consecutively diagnosed with IE in 7 hospitals in Andalusia (southern Spain) and registered in a dedicated database from January 1984 to December 2009. Five of the participating centers are tertiary referral hospitals for cardiac surgery, and 2 are community hospitals, where patients at higher risk are transferred to the referral centers for assessment for surgery. The information in this database was merged with data from the Vall d'Hebron Hospital database for IE. Vall d'Hebron is a 1000-bed teaching hospital in Barcelona, Spain, and a referral center for cardiac surgery, with a prospective IE cohort registered from January 2000 to December 2009. The specific variables included in both registri...

Invasive medical technology has led to an increase in the incidence of healthcare-associated infective endocarditis (HAIE). A prospective multicentre cohort study was conducted at seven hospitals in Andalusia, Spain, to establish the characteristics of HAIE and to compare them with those of community-acquired infective endocarditis (CAIE). HAIE was defined as either infective endocarditis (IE) manifesting >48 h after admission to hospital, or IE associated with a significant invasive procedure performed in the 6 months before diagnosis. Seven hundred and ninety-three cases of IE were investigated, and HAIE accounted for 127 (16%). As compared with patients with CAIE, patients with HAIE were older (60.1 ± 14.4 years vs. 53.6 ± 17.5 years) and had more comorbidities (Charlson index 3.3 ± 2.3 vs. 1.8 ± 2.3) and staphylococcal infections (58.3% vs. 24.8%). Vascular manipulation was the main cause of bacteraemia responsible for HAIE (63%). Peripheral vein catheter-associated bacteraemia accounted for 32.8% of the catheter-related bacteraemias. In-hospital mortality (44.9% vs. 24.2%) was higher in the HAIE group. Septic shock (OR 2.2, 95% CI 2.9-30.2) and surgery not performed because of high surgical risk (OR 1.6, 95% CI 1.2-20) were independent predictors of mortality in HAIE. The present study demonstrates that HAIE is a growing health problem associated with high mortality. Careful management of vascular devices is essential to minimize the risk of bacteraemias leading to HAIE.

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When the three age groups were compared,the AUROC curve for CCI was significantly larger for patients aged < 65 years(p < 0.001) for both in-hospital and 1-year mortality. Conclusion: There were no differences in the clinical presentation of IE between the groups. Age ≥ 80 years, high comorbidity (measured by CCI),and non-performance of surgery were independent predictors of mortality in patients with IE.CCI could help to identify those patients with IE and surgical indication who present a lower risk of in-hospital and 1-year mortality after surgery, especially in the < 65-year group.

L-amB induction treatment improves survival in patients with PVE-C. Medical treatment followed by long-term maintenance fluconazole may be the best treatment option for frail patients.