**Author details**

in in vitro studies [74]. According to one review of 15 isolates of *Abiotrophia* and *Granulicatella* species, all isolates were found to be susceptible to Rifampin with MICs ≤0.012 μg/ml [64].

Endocarditis caused by NVS is associated with high rates of complications including heart failure, embolization and valvular damage. The need for surgery and time of surgery remains to be determined. However based on outcomes of several cases published in the literature, the

he rate of valve surgery is high; 51% (in a review of 29 cases of *Granulicatella* endocarditis by Adam et al.) [50], 48% (review of 23 cases of endocarditis caused by NVS by Guiliano et al.) [49], 38% (review of 30 cases of endocarditis caused by NVS by Stein et al.) [41], 44% (review

A vegetation size of 10 mm or more is associated with increased mortality and increased risk of embolic events [76]. EASE Trial showed that early surgery in infective endocarditis in patients with large vegetations significantly reduced the mortality, risk of systemic embolism or recurrence of infective endocarditis (3% in the early surgery group vs. 28% in the conventional treatment group) [77]. Lin et al. [68] reported 7 out of 8 cases of endocarditis caused by NVS had large vegetation sizes (10 mm). In the same review, 7 out of 8 cases required surgery (4 out of 8 cases required early valve replacement due to severe heart failure, while 3 cases

Combined approach with antibiotic treatment and surgery provides the best outcomes in endocarditis caused by NVS. Specifically, early surgical intervention should be considered for those patients with heart failure due to valvular destruction [68], hemodynamic compromise

Infective endocarditis caused by NVS has posed tremendous diagnostic and therapeutic challenges and continue to do so even in the era of modern medicine. Delays in diagnosis due to difficulties in identification frequently cause delays in treatment and poor treatment outcomes. Treatment failure and high complication rates associated with *Abiotrophia* and *Granulicatella* endocarditis is at least partially attributable to the pleomorphic nature of the organisms, lack of growth in subcultures and specific nutritional requirements in media along with the need for the microbiology lab staff to have heightened awareness of these microorganisms. Their fastidious nature of NVS makes the antibiotic susceptibility testing fairly difficult, causing

Interpretation of the medical literature of *Abiotrophia* and *Granulicatella* spp. and its application to current clinical practice is challenging as the names of these organisms have been changed several times and not uncommonly the two genera were addressed together. There is

rate of surgical treatment is very high especially due to development of heart failure.

underwent mitral valve repair 2,4, and 7 months after the diagnosis of endocarditis).

of 9 cases of *A. defectiva* endocarditis by Hashimoto et al.) [75].

delays in initiation of timely and effective antibiotic treatment.

[49] or large vegetation sizes [68, 77].

**16. Conclusion**

**15. Role of surgery**

52 Advanced Concepts in Endocarditis

Gul Madison, Reshma Golamari and Priyanka Bhattacharya\*

\*Address all correspondence to: pbhattacharya@mercyhealth.org

Department of Internal Medicine, Mercy Philadelphia Hospital, Drexel University College of Medicine, Philadelphia, PA, USA
