title: Non-nosocomial healthcare-associated left-sided Pseudomonas aeruginosa endocarditis: a case report and literature review.
abstract: With the development of invasive medical procedures, an increasing number of healthcare-associated infective endocarditis cases have been reported. In particular, non-nosocomial healthcare-associated infective endocarditis in outpatients with recent medical intervention has been increasingly identified.
  
  
  
  A 66-year-old man with diabetes mellitus and a recent history of intermittent urethral self-catheterization was admitted due to a high fever. Repeated blood cultures identified Pseudomonas aeruginosa, and transesophageal echocardiography uncovered a new-onset severe aortic regurgitation along with a vegetative valvular structure. The patient underwent emergency aortic valve replacement surgery and was successfully treated with 6 weeks of high-dose meropenem and tobramycin. Historically, most cases of P. aeruginosa endocarditis have occurred in the right side of the heart and in outpatients with a history of intravenous drug abuse. In the case presented, the repeated manipulations of the urethra may have triggered the infection. Our literature review for left-sided P. aeruginosa endocarditis showed that non-nosocomial infection accounted for nearly half of the cases and resulted in fatal outcomes as often as nosocomial cases. A combination therapy with anti-pseudomonal beta-lactams or carbapenems and aminoglycosides may be the preferable treatment. Medical treatment alone may be effective, and surgical treatment should be carefully considered.
  
  
  
  We presented a rare case of native aortic valve endocarditis caused by P. aeruginosa. This case illustrates the importance of identifying the causative pathogen(s), especially for outpatients with a recent history of medical procedures.
authors.affiliation: Division of Infection Control and Prevention, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan. highgear@hp-infect.med.osaka-u.ac.jp.
authors.forename: Hideharu
authors.initials: H
authors.lastname: Hagiya
authors.affiliation: Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan.
authors.forename: Takeshi
authors.initials: T
authors.lastname: Tanaka
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Osaka University Hospital, Osaka, Japan.
authors.forename: Kohei
authors.initials: K
authors.lastname: Takimoto
authors.affiliation: Division of Infection Control and Prevention, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
authors.forename: Hisao
authors.initials: H
authors.lastname: Yoshida
authors.affiliation: Division of Infection Control and Prevention, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
authors.forename: Norihisa
authors.initials: N
authors.lastname: Yamamoto
authors.affiliation: Division of Infection Control and Prevention, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
authors.forename: Yukihiro
authors.initials: Y
authors.lastname: Akeda
authors.affiliation: Division of Infection Control and Prevention, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan.
authors.forename: Kazunori
authors.initials: K
authors.lastname: Tomono
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001021:Aortic Valve / Q000000981:diagnostic imaging* / Q000382:microbiology / Q000601:surgery; D004359:Drug Therapy, Combination; D017548:Echocardiography, Transesophageal; D004696:Endocarditis; D004697:Endocarditis, Bacterial / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000382:microbiology; D054092:Foramen Ovale, Patent / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D057928:Intermittent Urethral Catheterization / Q000009:adverse effects; D008279:Magnetic Resonance Imaging; D008297:Male; D000077731:Meropenem; D011552:Pseudomonas Infections / Q000000981:diagnostic imaging* / Q000188:drug therapy / Q000382:microbiology; D011550:Pseudomonas aeruginosa / Q000302:isolation & purification*; D013845:Thienamycins / Q000627:therapeutic use; D014031:Tobramycin / Q000627:therapeutic use; D018608:Ultrasonography, Doppler
chemical_list: D000900:Anti-Bacterial Agents; D013845:Thienamycins; D000077731:Meropenem; D014031:Tobramycin
keywords: Healthcare-associated infective endocarditis; Patent foramen ovale; Right-to-left shunt; Urethral self-catheterization